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,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z,FOR OFFICE USE: , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z�-�301� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2— <br /> (Complete <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 AUSTIN RD. - ONE-HALF MILE NORTH OF LATHROPC •US TRACT <br /> Owner's Name <br /> BILL KAMPS Phone 599-3089 <br /> Address <br /> 230 .0 SOUTH JACKTONE RD. City RIPON, CLL. <br /> Contractors Nameiii <br /> HENNINGS BROS. DRILLING CO. , INC. License # 290813 Phone 1522-1031 <br /> 2500 953 5 0 <br /> R L li , i <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 120 SEWER LINES PIT PRIVY well 601 <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 1 <br /> Industrial Cable Tool Dia. of Well Excavation ag 1c <br /> Domestic/private Drilled Dia. of Well Casing <br /> Ma W <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout en Onl e <br /> Disposal Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. C <br /> Type of Pump <br /> PUMP REPLACEMENT: / / <br /> State Work Done \� <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TCTION OF WELL: ell Diameter Approximate Depth d <br /> f^/ De cribe terial an Procedure <br /> I he y e to compl 31 law an re`v° a o the San JO -- cal Health District <br /> er <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 GROUTING AND A FINAL INSPECTION. B <br /> SIGNED HENNINGS BROS. DRILLING CO. ,INC . TITLE <br /> DRAW PLOT PLAN ON RE FRSE SIDE) <br /> F DEPARTMENT USE ONLY All <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _4 <br /> PHA �IGROT INSPECTION PHASE III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ 210 DATE <br /> ar6 3/76 2M <br /> E H 1426 Rev. 1-74 <br />