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1-�1ibf1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFLCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j .Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 3 - ski W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) '257- 2--co-os <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 /> 11 u S-t7 IJ ",', <br /> JOB ADDRESS/LOCATION Corner Melton & S. Austin Rds CENSUS TRACT <br /> Owner's Name C. M. Keyes <br /> Phone _-22.2"4494 <br /> Address 25843 S. Austin Rd. City Ripon, Cal <br /> Contractor's NameHennings Bros <br /> ni . Drilling Co. . Inc. #License 116322 Phone 522-5641 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /"7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: ( SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> W <br /> Industrial Cable Tool Dia. of Well Excavation 4W 12{' <br /> _X Domestic/private Drilled .Dia. of Well Casing ?T _ <br /> _ Domestic/public. _ _. _ . J)-riveny , ..�- �G.auge _o f„.Casing2. GA <br /> - <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other X _ Rotary Type of Grout y VA <br /> Other Other Information S,ZdE, <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. <br /> SIGNED_�26 TITLE <br /> • {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE bl3 <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTI N P Il F INSPECTION <br /> INSPECTION B DATE —Z INSPEC BY ATE .-7-L- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />