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SAN JOAQUIN LOCAL HEALIt DISTRICT <br /> -7-70T-6-1--nu E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �l 6 5T 4J <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 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 /> .FOB ADDRESS/LOCATION ���'' .� l� .� ,+'' f ..,. , �.. _.» � CENSUS TRACT � <br /> Owner's Name • fL � f Phone <br /> y*I' <br /> E' <br /> 5 <br /> Address City <br /> Contractor's Name HENNINGS BROS. DRILLING CO. 3 INC License # 116�2� Phone 522-5643_ <br /> 2500 W. Rumble Rd. Modesto C lif <br /> TYPE OF WORK (Check) : NEW WELL /711 DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PLW REPAIR / / PUMP REPLACEMENT /-7, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> b <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C3* <br /> Industrial Cable Tool Dia. of Well Excavation b 3 <br /> fi' Domestic/private !,.— Drilled Dia. of Well Casing }s'� <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �f 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 /> � <br /> 'UMP 'tEPAIR: / / State Work Done 2- <br /> � <br /> DF�TRUCTION OF WELL: Well Dihmeter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree .t-o •comply .with al.l.. Taws 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 /> [BELL 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 HENNINGS BROS. .-DRILLING CO. INC. TITLE [ <br /> (DRAW PLOT PLAN ON REVERSE. SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I eel <br /> APPLICATION ACCEPT BY ��� �':.: -,_�- DATE? <br /> ADDITI NAL CO, <br /> OFT INSPECTION PHASE III/FINAL INSPECT-ION <br /> INSPECTI Y` DATES 2. INSPECTION BY DATE <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br /> r <br />