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SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOWIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 1pistr�ct. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT - <br /> Owner's Name i <br /> Phone <br /> Address <br /> City <br /> Contractor's Name Hennings Bros. Drilling Co. .Ilc!. License # 29081 Phone 22--10. 1 <br /> 00 e Rd Modesto <br /> TYPE OF WORK (Check): NEW WELL &I DEEPEN /? RECONDITION /? DESTRUCTION _/ <br /> PUMP INSTALLATION /—/ PUMP REPAIR /� PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 ;_0- <br /> #.--Domestic/private Drilled Dia. of Well Casing .� <br /> Domestic/public 21 <br /> Driven Gauge of Casing N <br /> Irrigation Gravel, Pack Depth of Grout Seal <br /> Cathodic Protection __Rotary Type of Grout <br /> Disposal ' Other �� Other Information <br /> Geophysical Surface Seal Installed By:- - <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ' 'PAIR: /7 State Work Done <br /> ES-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 well, I will furnish the Sax: Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thein 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 /> SIGNEDD-rillina11,nning, TITLE <br /> DRAW L PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Ae <br /> ADDITIONAL COMMENTS: <br /> P SE GROUT INSPECTION P I FINAL INSPEC I <br /> INSPECTION BY DATE 6 INSPECTION BY DATE <br />`t lE H 1426 Rev. 1-74 PApi p <br /> _ _ ` �� ` r 1-74 2M <br />