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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FSR OFFICE USE: ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> Ly APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1'75 8 - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 -is-73 <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 �1���O 0. ,�u s f j`,�� CENSUS TRACT " <br /> Owner's Name MINARD ROORDA Phone 599-1029 <br /> Address 25960 SO. AUSTIN RD. RIPON, CALL city Ribon <br /> Contractor's Name Hennings Bros. Drilling Co.� Inc. License 4116122. Phone 522..5641 <br /> 2500 W.Rumble Rd. Modes o, Cal <br />- TYPE OF WORK (Check): NEW WELL /!i/ DEEPEN /7 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 DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> - <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casingge <br /> Domestic/public Driven Gauge of Casing 6► <br /> _0 Irrigation Gravel Pack Depth of Grout Seal • <br /> Other g Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ?}i013LF–M5 ., <br /> Type of Pump Q C9 L4 R ED , H.P. <br /> NO SLA13 — <br /> PUMP REPLACEMENT: / / State Work Done <br /> 5 j5'-/-7,3PUMP REPAIR: / / State Work Done <br /> a <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 I TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP ATE <br /> ADDITIONAL CO <br /> P GROUT INSPECTION P E II F AL INSPECTION <br /> INSPECTI BY DATE -�ZC� INSP ATE :20- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />