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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /># FOE OFFICE USE: " 1601 R. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209} 466-6781 <br /> 4 al at APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -M4--�-'— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/(� -Z <br /> (Complete In Triplicate) <br /> Application is�Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.'. 1662 and the Rules and Regulations of the San Joaquin Local Health District. ,; <br /> - 3 x <br /> JOB ADDRESS/LOCATION'- ' - CENSUS TRACT <br /> Owner':s Name �s Phone �S',_— ff . <br /> Address � '� - _ City - <br /> Contractor's Name HENNINGS BROS. .DRILLING CO. INC. .License # 290813 Phone '5'+5-1 185 , <br /> 2 PEL NDALE AV MUD ESTU <br /> TYPE OF WORK (Check): NEW WELL /X� DEEP RECONDITION. /_� DESTRUCTION 'f_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT L <br /> other %/ <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES PIT PRIVY ^� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC D SIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> 1ndustrla7 Cable Tool Dia. of Well Excavation 11�r <br /> Domestic/private Drilled Dia. of Well Casing1' PLASTIC <br /> Domestic/public Driven Gauge of Casing 16 0 WA L <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout BENTONITE <br /> _TDisposal Other Other Information LAB-BY OWNE <br /> Geophysical Surface Seal Installed By: DRIELER <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump gp . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 '- <br />�_PUMP�:REPAIR:= <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well•-construction'. Within FIFTEEN DAxS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and :notify them before putting the .well in .use.. The above <br /> information is true to the-best of y knowledge and belief. I WILL CALL TOR A GROUT INSPECTION. <br />' PRIOR TO GROUTING MJZINSOCTION. <br /> SIGNED TITLE C <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY �. <br /> PHASE I � <br /> APPLICATION ACCEPTED BY CA DATE ' `-,D _LA <br /> ADDITIONAL COMMFiiTTS: <br /> PHASE II GROUT INSPECTION PHA E III F- AL INSPECTIO <br /> INSPECTION DY DATE INSPECTION BY <br /> E H -1426 , X177 <br /> r <br /> 4 Rev. 1-74 - <br />