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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ;L_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZj x�-7� <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 BRENNEN RD- 1 WELL CENSUS TRACT s ' <br /> Owner's Name PHILLIP CHINCHILO &. SONS Phone 982-0344 <br /> Address 20848 E. RIVER RD. RIPON, CALIFORNIA City RIPON <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 116322 Phone 522-5643 <br /> TYPE OT WORK (Check):. NEW-WELL /g7 DEEPEN /_7 RECONDITION /_7 _DESTRUCTION /-7 x - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 T <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 n <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �r .... _ ' <br /> Domestic/public Driven Gauge of Casing 16" <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout - - — <br /> 'Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. w <br /> l- 1 <br /> \� <br /> PUMP REPLACEMENT: State Work Done 2-J 1--77— <br /> PUMP REPAIR: /% State Work Done2 v 7-lw 73 <br />,,DESTRUCTION OF WELI:: 'Well-Diameter Approximate Aepth <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 .oaf my knowledge and belief. t <br /> SIGNER -42 TITLE <br /> OT PLAN ON REVERSE SIDE <br /> FOle DEPARTMENT USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION — E ON P II INSPECTION^ �� <br /> INSPECTION BYv DATE I N S P BY TE 0 <br /> CALL FOR�AIGROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />