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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. __7 <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 /> JOB ADDRESS/LO TION CENSUS TRACT S <br /> Ownerts Name Phone <br /> Address City <br /> HENNINGS BROS. DRILLING CO., IN; <br /> Contractor's Name License # Phone j,,4 g_4�i ' <br /> 2500 W. RUMBLE ROAD <br /> TYPE OF WORK (Check): NEW WELL F-7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_/ PUMP REPLACEMENT /7 <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 J <br /> Industrial Cable Tool Dia, of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing til'1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ m <br /> Other Other Information <br /> O <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP REPAIR: / J State Work Done <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 orwregulating 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 be tt ogg y knowledge and belief. <br /> 14ENNINGS BROS. DMI LING <br /> SIGNED TITLE VRA__Q�1 A222 ( W PLOT PLAN ON REVERSE SIDE�� <br /> PHASE I F DEP6E&ET USE ONLY <br /> xiv <br /> Jz <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COi� <br /> A40-- <br /> P UT INSPECTION P I NAL INSPECTION <br /> INSPECTION BY DATE - -2--2--75 INSPECT DATE -73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />