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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOELX <br /> OF J USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. �� <br /> . .• <br /> Telephone: - (209)' 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR-PUMP PERMIT Permit No.DEC <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueV- 22 1971 . <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 f <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District'. <br /> JOB ADDRESS/LOCATION S.W. CORNER OF CARROLTON AVE. & ALLEN RD. CENSUS TRACT E <br /> ' . BLL''' AARLOSS 599-2729 <br /> Owner s Name I S Phone i <br /> Address -19535 S. CARROLTON AVE-. City '— RIPON <br /> Contractor's Name BENNINGS BROS . DRILLING ,GO. INC. License # 220813 Phone 45-118 <br /> 3.._2 "'Peland ale Ave. ,_Mod. „_.._ _ •t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK -PSEWER LINES - PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WAZL IOtW <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 2611 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 3/16 Gk 4 _ __. <br /> X- Irrigation _ - - Gravel Pack Depth of Grout Seal <br /> __ Cathod .c,Prate-ctionX... (Rotary -Type of Grout - '. <br /> Disposal Other Other Information SIAB-BY WNE <br /> Geophysical " Surface Seal Installed By: <br /> X/ <br /> PUMP INSTALLATION: Contractor',e' 7tfS�l <br /> Type of Pump' # H.P. <br /> PUMP REPLACEMENT: / / StateWork Done <br /> rPUMP-REPAIRr- - / / -State4'Work Dome <br /> 0 <br /> ..� <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approxi6ate 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:eon_struction: Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Jdaquiri_ -,Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the wdll in use. The above <br /> information is true to the best of.my,_knowledge and belief. I WILL CALLq/FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. BY TITLE <br /> RAW PLO , PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 'GROUT INSPECTION P SE W/FINAI, INSPECTI <br /> INSPECTION BY DATE ' /INSPECTION BY DATE <br /> - <br /> 1177 2M <br /> E H 1426 Rev. 1-74 <br />