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SAN JOAQUIN LOCAL HEALTH DISTRICT u� J� ttn <br /> FOE OFFYCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (2.09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !? -3C.14eJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )-I,;?--2z7 <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N.E. CORNER OF nH a ' f& HWY 132 CENSUS TRACT 1-5s-IfO-01 <br /> Owner's Name M.P. OLSON Phone <br /> Address P.O. BOX 708 City TURLOCK <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813Phone 522-1031 <br /> 2500 W. MUDESTO <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /4 DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST CATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1670SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,00 <br /> r ' <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLV,�-�"W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 . <br /> Industrial. Cable Tool Dia, of Well Excavation T 24" <br /> Domestic/private Drilled Dia, of Well Casing 1 n . <br /> Domestic/public Driven Gauge of Casingg'IA <br /> K Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information Slab- by QWner <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. rr <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 HENNINGS BROS. . �INC. BY TITLE SEC. <br /> DRAW PL10T PLAN ON REVERSE SIDE)-- <br /> FOR <br /> IDE)FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A2 7,7 7 <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHA I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE/ <br /> s�,r >7 3/76 2N <br /> E H 1426 Rev. 1-74 <br />