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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> AP LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. KI9cr� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-14- <br /> (Complete <br /> /_/4-(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> f JOB ADDRESS/LOCATION . CENSUS TRACT <br /> . MIKE EISENGA WEST SIDE <br /> Owner's Name Phone 982-09.59 <br /> I Addr 'ss 1 00 E. ELSHOLZ RD. City . RIPON <br /> Cori Tractor's Name HENNINGS BROS. DRILLING CO.. INC. License # 2908.13 Phone 522--1031 <br /> Y <br /> 2200 W: U - <br /> t TYPE OF WORK (Check): NEW WELL -X7 DEEPEN '/7 RECONDITION f7 DESTRUCTION /-7 <br /> PUUMPrP /7 /7 <br /> INSTALLATION J / UMP REPAIR - PUMP REPLACEMENT , . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> fa-es�- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER S ►�r�ak'a�a <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 it <br /> Domestic/private Drilled Dia. of Well Casing _ —j ILI' <br /> - -- Domestic/public Driven Gauge of Casing <br /> -_ �— Irrigation _ Gravel Pack". Depth of Groat Seal <br /> Cathodic Protection XRotary Type of Grout <br /> Disposal :{ Other; Other Information ' <br /> . Geophysical : Surface Seal Installed BY: ..;. . _ . <br /> PUMP INSTALLATION:, Contractory:. <br /> Type of Pump H.P. <br /> } PUMP"REPLACEMENT / / State Work Done <br /> ,PULAR' .REPAIR: / ;/ - State; Work Done <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Pro1 .cedure \ <br /> . . <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 anew well, I will furnish the San Joaquin Local Health District <br /> 4 WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use... The above <br /> l information is true tothe•best -of my. knowledge and belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> + PRIOR TO GROUTING AND A FINAL INSPECTION_. <br /> SIGNED RENNTNGS ---BROS, DRILLING CO. INC . . BY TITLE SEC: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �­ <br /> F4 DEPARTMENT USE ONLY <br /> PHASE I f <br /> ( APPLICATION ACCEPTED B DATE <br /> ?_ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I NALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 4<75 2M <br />