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f7P SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 8 OFFICE US * 1601 E. Hazelton �ve.z •Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION AUSTIN RD...1 JMI NORTH OF FRENCH CAMP RD,. CENSUS TRACT <br /> 1MI WEST OF AUSTIN RD. <br /> Owner's Name B & B FARMS Phone 599-4220 <br /> Address 27011 S. AUSTIN RD. City RIPON <br /> Contractor's Name HENNINGS BROS. DRILLING CO. $INC. License # 29081 Phone 522-10M <br /> 2500 W. RUMBLE RD., MOD <br /> TYPE OF WORK (Check) : NEW WELL �_/ DEEPEN%/ RECONDITION /_7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK lone—, SEWER LINES /Zr E PIT PRIVY <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 . <br /> Industrial Cable Tool Dia. of Well Excavation 1117 <br /> X Domestic/private Drilled Dia. of Well Casing 6" plastic <br /> Domestic/public Driven Gauge of Casing 1 0 <br /> wall <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br />! Cathodic Protection — Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab-Ty—owner <br /> Geophysical Surface Seal Installed By: dr1jjer <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> h DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED BENNINGS BROS. DRILLING CO. INC . BY TITLE <br /> r,(DRAW PLOT PLAN ON RE PI SIDE T1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q �^ Z �: <br /> APPLICATION ACCEPTED BY d/�Lo DATE �- 7 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PfLASE III/FINAL INSPECTIO ° <br /> INSPECTION BY A E INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />