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' r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. HazeltonAve.. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> - k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-�5--7� <br /> (Complete In Triplicate) . <br /> Application is hereby made tib 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:-1$62 and' • the Rules and Regulations 'of the San -Joaquin Local Health District. <br /> UNION RD- & PERRIN RD.42600' EAST OF UNION RD. °& . <br /> JOB ADDRESS/LOCATION 1 4 f SOUTH OF PERRIN RD'. '� CENSUS TRACT <br /> Owner's Name FRANK MACHADO Phone ' 823-48�1+ <br /> F <br /> Address.:... - 26Q4 S. UNION -RD. MANTECA <br /> 4 Contractor's Name HENNINGS -BROS. DRILLING C.O. INC. License # '2 208 j Phone 522-10�1� <br /> 2 00 W. RUMBLE RD. , MOD. <br /> TYPE- OF WORK (Check) : NEW WELL /27 DEEPEN'J? RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / -f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC €TANK4 SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool . Dia. of Well">Excavation . e 26" <br /> Domestic/private r Drilled Dia. of Well Casing +_ - <br /> Domestic/public , --Driven Gauge_of,Casing. ;LQrA <br /> X Irrigation X Gravel Pack Depth of"Gr uo t' Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal s. Other Other Information , lab_ by gk[oer <br /> Geophysical € Surface Seal Installed 'By_ <br /> PUMP INSTALLATION:. Contractor - <br /> Type l Pump ' A.P. , - <br /> G C� <br /> PUMP REPLACEMENT: .' State Work Done <br /> PUMP �REPAIR: /% State Work Done " r:... . <br /> DESgTRUCTION OF. WELL: Well Diameter Approximate Depth <br /> Describe Material ajLd Pro ce urs <br /> I hereby agree to comply with al aws and regulations of th San Joaqbin Local. Health District <br /> and the State of Californiapertaining to or regulating well construction. Within FIFTEEN DAYS <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.:wel1 in.use.... .The above <br /> information is true to the•best-of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING. CO. INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />-PHASE I <br /> FOR DEPARTMENT USE ONLY,;-=, <br /> s � }. ._ .: <br /> 1APPLICATION ACCEPTED BY rs DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIKAO FIN INSPECTION- <br /> WSPECTION BY ATEYNSPSCTION BY DATE <br /> 11. 1426 _Rev. -74", b: r /*7< 9M <br />