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SAID JOAQUIN LOCAL HEALTH DISTRIC� + <br /> FOF.OFFI- E USE: 1601 E. Hazelton Ave. , Stockton, Calif.(o-r�14 "115 HIP <br /> gr!4c r> <br /> Telephone:, (209) 466-6781 r,'jD,,a,? t'/'. <br /> (� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT + Permit No. .;ZF'_/36,1_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2-12-7p <br /> Application is hereby made to the San Joaquin Local Health District for a permit too 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 /> 7i7s �/ c <br /> JOB ADDRESS/LOCATION ALTGF AVE.a-MILE NORTH OF W. RIPON RD. . CENSUS TRACT <br /> Owner's Name WILLIAM DE JONG JR. EAST SIDE Phone 599-2592 <br /> Address 13776 W. RIPON RD. City RIPON <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone 545-1185 <br /> X .25 PELANDALE AVE. , MOD., CA. 9 350 <br /> TYPE OF WORK (Check) : NEW WELL /x% DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK 1OO + SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD loot+ CESSPOOL/SEEPAGE PIT _ OTHER O <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 1 " <br /> X Domestic/private Drilled Dia. of Well Casing " PLASTIC — <br /> Domestic/public Driven Gauge of Casing 160 WALL �( <br /> Irrigation X Gravel Pack Depth of Grout Seal 501 /f1 <br /> Cathodic Protection aX Rotary Type of Grout BENTONITE 1v <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. ``- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 San Joaquin Local Health 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 GROU ING AND k F.1-NAL INSPECTION. � <br /> SIGNED TITLE <br /> (ERA PLOT PL ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TION PHASE T-TI/FINAL INSPECTION <br /> INSPECTION BY DATE — INSPECTION BY DATEftQ• — <br /> ��/5�� ��� � <br /> °'77 <br /> E H 1426 Rev. - I-74 / `� <br />