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A._ y 0SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone• (209) 466-6781T <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEFJUT Permit No. 77 I3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ate Issued <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 f the San Joaquin Local Health District. <br /> 4JOBADDRESS/LOCATIONZ65!?�U <br /> ST`+v CENSUS TRACT <br /> Owner's Name C Phone 599-4229 <br /> Address 20011 S. Austin Rd. City Ripon <br /> Contractor's Name Hennings Bros, Drilling Co. ,Inc. License_ # 2 0 13'hone 522-10 .1 <br /> 2500 W. Rumble Rd. . Mod, i <br /> TYPE OF WORK (Check) : NEW WELL/17 DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /—/ PUMP REPLACEMENT /_ <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOLIPEEPAGE PIT OTHER <br /> Z <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL M"i PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2611 <br /> Domestic/private Drilled Dia. of Well Casing 1611 <br /> Domestic/public Driven Gauge of CasingA <br /> X Irrigation X Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information Slab- by owner <br /> Geophysical Surface Seal Installed By: «• <br /> PUMP INSTALLATION: Contractor ��� C7/<-- <br /> Type of Pump ?.Q " H.P. gj^ <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 T U ING FIN INSPECTION. , <br /> SIGNED TITLE <br /> !',(DRAW MOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,�p <br /> APPLICATION ACCEPTED BY DATE �7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR INSPECTION PHAjSE,j4,y/FIN,4 INSPECT ON <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74 376 2M ___ <br />