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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 2-/01 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I- 1z- .3 k3�1 4 <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 Joaquit' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 17283 Hwy 120 CENSUS TRACT <br /> Owner's Name . ,-W. B. LoopPhone ,� <br /> Address 17283- �FiWY 120 . r <br /> city <br /> Contractor's Name Henningahroa. Drillii6g Go. Inc . License # 116322 Phone 522-5643 <br /> } <br /> TYPE OF WORK (Check) : NEW WELL /X-7 DEEPEN /_/ RECONDITION /_/ 'DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation ll <br /> X Domestic/private Drilled Dia. of Well Casing W , <br /> Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Groutenf <br /> Other Other Information <br /> MEN <br /> PUMP INSTALLATION., Contractor <br /> Type of, Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> : ... _. <br /> PUMP—REPAIR:- - - -- —State Work Done <br /> µ <br />,�}ESTRUCTION 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 onia new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDe � �� ;- __ TITLE <br /> A14 - - - i -(DRAW PLOT PLAN ON_ REVERSE SIDE <br /> i <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _��, - — � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION tgNPHASE �tI �EIp AL INSPECTION <br /> INSPECTION BY DATE INSPECY' +i (, / DATE 7-- �� <br /> CALL FORA GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> R H 1426 7/72 1M <br />