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V JAM JUAttUln LULAL rn a.ALln UlJlnit.l <br /> FOF, OFFICE USE: 1601 �. Haveitep Ave. , Stockton, Calif- <br /> �,selephone: (209) 466-6781 u <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2b-3 {J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5- 8'.76 <br /> (Complete In Triplicate) <br /> kpplication 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 /> lounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Lo✓ <br /> JOB ADDRESS/LOCATION 5101 bete Rd. on Old Hwy 50 at Curve CENSUS TRACT <br /> Dwner's Name DON COSE Phone 835-0966 <br /> Address P. 0. BOX 326 City Tracy, Cal <br /> Contractor's Name Henninger Bros . Drilling Co. , Inc. License 11290813 Phone 522-1031 <br /> 2500 LV Rumble Rd Modesto Calif- <br /> TYPE <br /> alif TYPE OF WORK (Check) : NEW WELL E/ DEEPEN / / RECONDITION /_/ DESTRUCTION /-] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> QT$TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> X 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 1211 C <br /> X Domestic/private Drilled Dia. of Well Casing j 611 <br /> Domestic/public Driven Gauge of Casing 1 0 P <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout Bei tonit <br /> Disposal Other Other Information Sl owner <br /> Geophysical Surface Seal Installed By: drille r <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 FI INSPECTION. <br /> SIGNED TIT <br /> DRAW P T PLAN ON REVERSE tm t/ <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE $• (� <br /> ADDITIONAL COMMENTS: <br /> PRAfPHA E II G OUT INS ECTI PHASE III/FINAL IRSPECTI67/ <br /> II G <br /> INSPECTION BY DATE . 5 INSPECTION BY DATE <br /> 7 <br /> E H 1426 Rev. 1-74 a �"A't. - 3 76 2M <br />