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SAN JOAQUIN WCAL-JiEALTH DISTRICT <br /> FOE.OFFICE USE; 1601 E. Hazelton 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 -.57, G <br /> (Complete In Triplicate) <br /> -pplication is hereby Nada to the San Joaquin Local health District for a permit to construct <br /> .nd/or install the work herein described. This application is made in compliance with San Joaqu! <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION 1 g -VAN ATj,RN R1)._-1MT NnRTH OF HWY 12 PENSUS TRACT <br /> ST SIDE <br /> waer I s Namd ROBERT -MATHIAS Phone 818..7 61 <br /> ddress 1732 7 S . VAN ALLEN RD. City MAN` 8 A <br /> ontractor's Name N_ NTNC,�,,_BROS. DRJ . .TN = ,C0. S Ilic. License # 29081 Phone 522-1011 <br /> MO <br /> YPE OF WORK (Check): NEW WELL A7 DEEPEN/7 RECONDITION /7 DESTRUCTION .d7 <br /> PUMP INSTALLATION/7 PUMP REPAIR/? PUMP REPLACEMENT <br /> 0 they / <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES 1 , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ae//-/O" <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of elI Excavation 1111 <br /> X._ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven ­Gauge of Casing- — _. •^-� <br /> Irrigation Gravel Pack Depth of Grout Seal 511 <br /> Cathodic Protection �_ Rotary Type of Grout __RPntnnitP <br /> Disposal Other Other Information Al ah., hv_ nwner <br /> Geophysical Surface Seal Installed BY: rt11 -r <br /> UMP INSTALLATION: Contractor <br /> Type .of Pump - - H.P. . .. <br /> UMP REPLACEMENT: L/ State Work Done , <br /> :TMF -.REFAIR: /? tate Work Done , <br /> iSjRUCTION OF Wim. Well Diameter Apprd:fizate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> iformation is true to the-beat of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> aOR TO GROUTING AND A FINAL INSPECTION. <br /> [GNED _HENNIN gS BROS. DRILLING CO. INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> WR DEPARTMENT USE ONLY <br /> 1ASE I <br /> ?PLICATION ACCEPTED BY DATE ' <br /> )DITIONAL COMMENTS: <br /> P I INSPECTION PHASESII INSPECTIO <br /> ISPECTION BY DA?B INSPECTION BY DATE <br />