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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOFx:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f •w Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 2 <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 Joaqu Loc Heal h District <br /> c3`03g3F. � o v . <br /> • _.�. ..�.. /� C� ��GGd�/�/�� ��?SIO U�'<�L�g� f�I��f. <br /> r JOB ADDRESS/LOCATION _QUngeAve. & ut ife .Rd', r CENSU TRACT zk <br /> Owner's Name Milton Griffin Phone <br /> r <br /> .Address 25897 'Magnolia Ave. City Escalon <br /> Contractor's Name Hennings Bros. Drilling ,Co. ,Inc. License # - 2go$13Phone 522,-1031 <br /> Modesto. <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN /7 RECONDITION /_7 DESTRUCTION 17 Q <br /> PUMP INSTALLATION %/I PUMP REPAIR%J PUMP REPLACEMENT 1_7 <br /> Other {// <br />� ; W <br /> .DISTANCE TO NEAREST: SEPTIC TANK 7,41" SEWER LINES PIT PRIVY- <br /> SEWAGE <br />' tiL_ i <br /> DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + +1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL ! <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> fIndustrial Cable Tool Dia, of Well Excavation <br /> Domestic ra <br /> Aa.._�f Ke aging _hrr <br /> : Domestic/public Driven - Gauge of Casing _ 1 Fin i;�a l <br /> Irrigation Gravel Pack Depth of Grout Seal : wl <br /> s Cathodic Protection X - Rotary . <br /> Disposal , Type of Grout o <br /> Other Other Information. <br /> -Geophysicalf <br /> , lab--bv owner <br /> Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> ,._ A.P. <br /> PUMP REPLACEMENT State Work Done ' <br /> PUMP '.REPAIR: ::, <br /> �/4/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter* <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 77 <br /> { ; <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 willYfurnish the San Joaquin Laval Health Districts <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-oE my_knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED HENNINGS BROS . DRILL INC. BY TITLESEC-. <br /> "_-1-./ �ew_� <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT <br /> PHASE I USE ONLY - <br /> --- <br /> A PLICATION ACCEPTED!BY DATE 2 <br /> ADDITIONAL COMMENTS: # <br /> PHA"A)[_)0RoVT INSPECTIO INSPECTION B��� PHASE, Ii F1NALiINSP$CTY N <br /> INSPECTION BY DAT$ INSPECTION BY _1Z DATE /J <br />