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�- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave.', Stockton, Calif. <br /> -------------- <br /> j Telephon6:. . (209) .46b=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L f Z <br /> THIS PERMIT EXPIRES- 1-YEAR-FROM DATE ISSUED Date -Issued .2 1 a� <br /> (Complete Iri 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 SanjJoaquin <br /> County Ordinance No. 1862 and the Rules; and Regulations ofzthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I0D CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address loge ...u. City. .1 . <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 17.6322 Phone 522--5643 <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN177 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUIV REPAIR/ / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1211 <br /> Domestic/private Drilled Dia. of Well Casing Aim <br /> Domestic/public Driven Gauge o€' Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Other X Rotary Type of Grout Bentonite p <br /> Other Other Information ' A <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of PumpSr /� ^ Q. - -- H.P. <br /> - -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done y <br /> DESTRUCTION OF WELL: Well Diameter 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 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 my knowledge and belief. <br /> SIGNEDFTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FINAL INSPECTIO <br /> k INSPECTION BY Q�D „� DATE X71 INSPEC ON BY DATE Z <br /> ` CALL. FOR A GROUT INSPECTION PRIOR TO GROUT NG AND PIN INSPECTION. <br /> E H 1426 - -_. _ _ .. .. . _ 4/72 1M <br />