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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,2j,:S lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L=2_T 73 <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-an�1 the Rules and Regulations of the Sari Joaquin Local Health District. <br /> CENSUS TRACT <br /> jbB ADDRESS/LOCATION w <br /> Owner's Name Phone 82 -691 0 I <br /> Address 124 iCity MA TA <br /> �. E. JAMISON RD. i <br /> Contractor's Name BENNINGS"BROS.- DRILLINGTC-0. $INC License,11__,1,1,63,p 2Phone .-522-5643, <br /> 2 00 W. Rumble Rd. Modesto <br /> TYPE OF WORK (Check) : NEW WELL /E/ DEEPEN -/_/ RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> /� -� <br /> Other 17 <br /> — N <br /> w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LIN S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '2/'i ESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation- 11 <br /> Cj <br /> Domestic/private Drilled Dia. of Well. Casing 1611 <br /> Domestic/public Driven Gauge of Casing r� <br /> Irrigation �� Gravel. Pack Depth of Grout Seal � a+ ��/ <br /> Other X Rotary Type of Grout ' <br /> Ot er Other nformation Slab by <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H'P. <br /> 4 PUMP REPLACEMENT: / / State Work.Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DF-,TRUCTION 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 w n I wi 4' _furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well anc y them before putting the well in use. The above <br /> information is true to rhe best of Goiwledge andbelief. r� <br /> SIGNED TITLE <br /> (pRAW'P T--PLAN ON REVERSE SIDE} <br /> DEPARTMENT USE ONLY <br /> r PHASE I <br /> APPLICATION ACCEPTED .BY DATE 7-� ; <br /> ' ADDITIONAL COIMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIONjaq <br /> .. <br /> INSPECTION BY ' �,�� DATE INSPECTION BY DATE <br /> 4 ` CALL FOR A GROUT INSPECTION PRIOR TO GROUTING. AND FINAL INSPE ION. <br /> - - - -- 5/73 ._ - <br />