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Q) 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. ZT-fV <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 cork 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 Funk Rd. _ r � �i_- CENSUS TRACT <br /> Owner's Name Herb Mc Williams Phone <br /> Address 1501 Cherrywood Drive City Modesto, Ca. <br /> Contractor's Name Hennings Bros. Drilling Co. I Inc. License # 116322 phone 522-5643 <br /> f500 W. Rumble RE[. Modesto, Ual. <br /> TYPE OF WORK (Check): NEW WELL J / DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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�SPE CIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 16TT <br /> Domestic/public Driven Gauge of Casing 16"x Pt <br /> X _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary .; Type of Grout <br /> Other 'Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP REPAIR° / / State Work Done <br /> PES_TR_U_CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure w <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 /> SIGNED TITLE <br /> (D AN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I Z 3 3 <br /> APPLICATION ACCEPTED BY DATE Z - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BX DATE <br /> h CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />