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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelto-n Ave: , Stockton, Calif. <br /> 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 <br /> (Complete In Triplicate) 4 <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/ ��' _1 MILE SOUTH OF HWY 120-- CENSUS TRACT <br /> EAST SIDE <br /> Owner's Name MARVIN LUTZ CONT. Phone 982-0945 <br /> Address 10306 S . JANET AVE. City FRENCH CAMP <br /> Contractor's Name HENNINGS BROS. DRILLING CO. j INC. License # 290813 Phone 51+5-118. 5 <br /> 3525 PELANDALE AVE., MOD. , CA. <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN f / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 100t SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1001+CESSPOOL/SEEPAGE PIT OTHER U <br /> PROPERTY LINE - PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL zat <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation 1111 <br /> X Domestic/private Drilled Dia. of Well Casing PLASTIC <br /> Domestic/public Driven Gauge of Casing 160 WALL <br /> Irri-gation X Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout BENTONITE <br /> Disposal Other Other InformationS.LA13-BY OWNER <br /> Geophysical Surface Seal Installed By: <br /> URIELEIT- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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. <br /> SIGNED FIENNINGS BROS. BYa& TITLE SEC'. <br /> (DRAW PLOT PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G <br /> APPLICATION ACCEPTED BY DATE �_ -7`7a <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> °II/FINAL INSPECTION <br /> INSPECTION BY D1 U L INSPECTION BY DATE <br /> i <br />