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SAN JOAQUIN LOCAL HEALTH DISTRICT? <br /> FOF OFFICE USE: .1601 E. Hazelton .Ave:, Stockton, Calif: `rt <br /> ^ ' <br /> " Telephone:hone <br /> i P (209) 466-6781 �/ �/ <br /> APPLIICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 7-/7(l4 <br /> 14 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1� <br /> ro� (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct' <br /> C and/or install the work herein described. This application is made in compliance with San Joaquin <br /> 4 County Ordinance No.. 1.862- <br /> -562 and the Rules and Regulations of the" San Joaquin Local Health District. <br /> LQ <br /> kJOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ' MARY AZEVEDO WEST SIDE Phone 523--3156 <br /> Address 7 -. 2129 CHRYSLER DR. _ City . MODESTO <br /> t <br /> Contractor's Name HENNINGS BROS. DRILLING CO«�I,NG. License �� 290813Phone 5t+5-11 5 <br /> 2 PELANDALE AVE , MOD.;, ` <br /> TYPE, OF"WORK (Check) : NEW WELL XIT_DEEPEN / / _RECONDITION DESTRUCTION <br /> M _ PUMP INSTALLATIONS/_/ PUMP +REPAIRT/- / PUMP REPLACEMENT /_7 <br /> ��. .Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK ] f SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of Well Excavationtr ` <br /> Domestic/private Drilled Dia, of Well Casing 1Oil <br /> Domestic <br /> /Public Driven Gauge of Casing 16 GA _ <br /> Irrl:.gation X Gravel Pack �.� Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> y <br /> �_ Y Type-of Grout <br /> p <br /> GeoOther � Other 'Information `SLAB-BY OWNER <br /> Geophysical Surface' Seal Installed By: �, r <br /> PUMP INSTALLATION: Contractor ' <br /> ` Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION °OF WELL: Well Diameter F f <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby;agree to comply with all�-laws and regulations -nf--the---San-Joaquin--L-ocal Health District <br /> and. the State of Calffornia"�per'tainng, to or regulating we11 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on,�a;new'jwell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thewel.l -and,.notify them before putting the well in use. The above <br /> informationiis true to the b"est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL, INS'ECTION. ! <br /> SIGNEDHEN TINGS L�L <br /> O - S�+E'[�Cn <br /> TITLE - 1LJ� <br /> (DRAW PLOT PLAN ON VERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY # <br /> PHASE I ,r <br /> APPLICATION `ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' P S I/F AL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BYjdye4M4DATE - <br /> 1 E H 1426 Rev. -74 1 <br /> _ ]/77 � <br />