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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. u/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued zy <br /> (Complete In Triplicate) <br /> Application is hereby 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1024 Forest Lake Rd. CENSUS TRACT <br /> Owner's Name JHRD - 105 Phone 599-2168 <br /> Address 1020 Forest Lake Raod City Ackmpo; Cal. <br /> Contractor's Name Hennings Bros. Drilling Co., Inc. License # 290813 Phone 522-1.0 1_ <br /> 2500 W. Rumble Rd. Modesty California <br /> TYPE OF WORK (Check) : NEW WELL /x II DEEPEN/ / RECONDITION %/ DESTRUCTION /;T <br /> PUMP INSTALLATION J / PUMP '..REPAIR/ / TPUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6001 SEWER LINES 6001.*1 PIT PRIVY � <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PNI <br /> INTENDEMSE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. {of Well Excavation' ' <br /> t Domestic/private Drilled Dia. of Well Casing ZA - ^t' <br /> t Domestic/public r'/.. Driven Gauge of Casing W - -- -- 411 <br /> Irrigation :) ¢ $. Gravel Pack Depth of Grout Seal <br /> Other #`' X. Rotary Type-of Grout <br /> ' Other Othe ' Information Slab by Ovmer <br /> PUMP' .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP ,REPLACEMENT: State Work Done <br /> PUMP 'REPAIR:, / / State Work Done <br /> ,DFQTRUCTION OF WELL: WelliDiameier � - Approximate Depth <br /> Describe Material and Procedure <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 DAYS <br /> after Completion of my work on a new well, I will b.furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of <br /> �ihe well and notify them efore putting the well in use. The above <br /> information is true ,fo the best of my knowledge and belief. <br /> SIGNED TITLE <br /> - (15RAWPLOV FLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ti PHASE I <br /> APPLICATION ACCEPTED DATE 7/ <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION .- j PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION ,BY DATE /,2- <br /> CALL FOR A (TROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />