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SAN JOAQUIN LOCAL HEALTH DISTRICT Q� i <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ocL•ton, Calif. r Q 1 <br /> Telephone: (209) 466-6781 /I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 749,9 4e/ <br /> jr <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,5r'V 7 <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 District. <br /> JOB ADDRESS/LOCATION 2 q326 S. Fredrick Rd.-lmile south of West CENSUS TRACT <br /> Ripon Rd. 9 East side <br /> Owner's Name Joseph Visser Phone 599-3804 <br /> I <br /> Address 25326 S. Fredrick Rd. City Ripon <br />` Contractor's Name Hennings Bros. Drilling Co. gInC. License # 29081 -'hone 522-1031 <br /> 0 X. Rumble Rd. Mod. i <br /> TYPE,OF WORK (Check) : NEW WELL/V` DEEUEN / / RECONDITION I I DESTRUCTION <br /> PUMP INSTALLATION .�/ PUMP REPAIR'/ / PUMP REPLACEMENT <br /> Other /_7 . <br /> DISTANCE TO NEAREST: SEPTIC'TANKSEWER LINES PIT PRIVY 10 <br /> SEWAGE DISPOSAL FIELD 4GQ�+ CESSPOOL/SEEPAGE PIT OTHERGtr - W0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U`y <br /> Industrial Cable Tool Dia, of Well Excavation, 22 <br /> X Domestic/private Drilled Dia. of Well Casing 81' nl.astiC_- <br /> -yDames_tic/pub.l -c.� - - =Driven = - Gaugeaof=Casing_ -. _ - <br /> Irrigation. Gravel Pack Depth of Grout Seal . 01 <br /> Cathodic Protection Rotary 'Type of Grout Bentonite <br /> Disposal Other Other Information Slab-by owner__ <br /> Geophysical Surface Seal Installed B driller <br /> J� Of <br />'. PUMP INSTALLATION: Contractor <br /> e um H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .PUMP .REPAIR: /_ / State. Work Done <br /> A Approximate' -ep h <br /> DESTRUCTION OF WELL:, Well Diameter <br /> ' Da ribe Mater ' 1 and Procedure - ---.. . zErr 59-P <br /> ll <br /> I hereby agree to comply, with a 1 laws an regu a ons o the an aquin Loc ealth District <br /> and the'"of'Cal fo_rnia_rpertain ing to or regulating we11 ''construction. Wi h r� FI EEN DAYS <br /> e`Stati <br /> after completion of`,.., work on a new wel27'Ill'w ll- furnish,=the, Sa_n Joaquin_LocalaHealth District a <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. " <br /> SIGNED. Hennings Bros. Drilling o. Inc. " by TITLE ` Se <br /> DRAW PIS T PLAN ON REVERSE SIDE <br /> U YFORPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ` <br /> i <br /> PHA GR UT INSPECTI PRA32-)III/M& INSPECTIO <br /> INSPECTION BY - DATE INSPECTION BY DATE <br /> -9 1-7177 <br /> Sa ' u1'� 1 i 3/76 2M <br /> E H 1426 Rev. 1-74 WeIj ` <br />