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C � � 'V91 SAN J'OAQUIN LOCAL_ HEALTH DISTRICT <br /> FOE,OF�iCE USE: " 1601 E. Hazelton Ave,, :Stockton, Calif. '• <br /> *" Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7a�o W <br /> 1 <br /> THIS, PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED Date issued �6 ` <br /> t j (Complete In Triplicate) <br /> Applic4tion is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> co <br /> and/or install the work herein described. This application is made in compliance- with. $an Joaquin - <br /> County Ordinance No. 1862 and.=the Rules and 'Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION30 21 E. 1 HALL RD. BETWEEN MC BRIDE & HENRY A 1$US TRACT <br /> f <br /> 1 FRANK BAVARO Phone 83 8-2651 <br /> Owner s Name <br /> F 265312 EAST JONES AVE. ESCALON, CAL.. <br /> Address City <br /> Contractor's Name' HENNINGS BROS . DRILLING =L, INC. Licens �2. 0813 Phone 5221031 <br /> STO IF. 953 : <br />`TYPE OF WQRK (Check) : NEW WELL /X DEEPEN;'/� RECONDITION 1-T DESTRUCTION /�. z <br /> PUMP INSTALLATION / / PUMA' REPAIR / / PUMP REPLACEMENT . �7. <br /> Other k <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES XFe PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,gam_ CESSPOOL/SEEPAGE PIT OTHER (J <br /> PROPERTY LINE --P*I9TE 'hMESTIC WELLkCf PUBLIC DOMESTIC WELL <br /> INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS'2rr. Q <br /> IndustrialCable Tool Dia. of Well Excavation <br /> �- Domestic/private __7X Drilled Dia." of Well Casing n , <br /> V�Domestic/lubl�.c Driven Gauge of. Casing �u <br /> r Irri atian _ Graver_Pacic 'DthyQFGrautrSeal ._ _ . O t <br /> g.. t _ t <br /> Cathodic Pr`a.tection. � Rotary Type of Grout Bentorii 2 <br /> l Disposal ,; Other Other Information Slab b owner <br /> ,� � Surface Seal. Installed B ter` 1 <br /> Geophysics]. ;.. <br /> PUMP INSTALLATION: � Contractor <br /> Type of Pump H.P. <br /> n <br /> af.rw.1F''r.'•ar"+wva..... <br /> PUMP -REPLACEMENT: "/ /, P State,Work Done. r -- <br /> t # 4 <br /> t PUMP `REPAIR: �• /_7 State Work Done. <br /> DESTRUCTION OF. WELL: Well Diameter proximate Depth <br /> j Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulationszof the San .Joaquin Y.oca1 Health istrict <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' s <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 CALF FOR A GROUT INSPECTION <br /> PRIOR T0. ROUTING AND A FINA INSPECTION. <br /> SIGNED <br /> (DRAW PL T PLAN ON FRSEIDE <br /> F DEPARTMENT USE ONLY <br /> c PRASE I DATE <br /> APPLICATION ACCEPTED BY <br /> f ADDITIONAL COMMENTS: <br /> P II GROUT INSPECTION <br /> 4PHMWASII,/F11N11AL INSPECTION,?INSPECTION $Y DATE --� � INSPECfTT N DA E�� , <br />