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y SAN JOAQUIN LOCAs-HEALTH DISTRICT <br /> FOSiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (-/��GJ <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 3-i1-76 <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. 186 apj h Rq;ea and Regulat_ aD of -the San. Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ©o 5 �1, <br /> �/?. - l CENSUS TRACT V. . <br /> Owner's Name RICHARD L'IAL Phone ' 838-2901 <br /> Address 19624 SO .VAN ALLEN City Escalon ,, Cal <br /> I <br /> Contractor's Name Hennings Bros . ' Drilling Co. , Inc.. Li j290813 Phone 522--1.031 r <br /> . , <br /> TYPE OF WORK (Check): NEW WELLJg7 DEEPEN '17 RECONDITION /7 DESTRUCTION r7 ; <br /> PUMP INSTALLATION "/ / PUMP REPAIR-/_7 PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST:V SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11 n <br /> __X Domestic/private Drilled Dia. of Well Casing, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection en onz eRotary Type of Grout n. <br /> Disposal Other Other Information Sla,b by owne r a <br /> Geophysical Surface Seal Installed 'B : _ D <br /> PUMP INSTALLATION Contractor i <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: ' <br /> State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: 'Well Diameter Approximate Depth i <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 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR 'TO GROUTING AND A FINAL INSPECTION. BY: I <br /> SIGNED HENNINGS BROS. DRI I . , INC. TITLE SEC T t <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ICOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y f� <br /> DATE <br /> ADDITIONAL COMMENTS;- QC4 rc A7 Ci <br /> PHASEII,GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ESR �47� Deas 7_7/. We �C � g 'el rr � }. /.sty nu <br />