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r u.. .. V ` // - - -�-- <br /> /�r_1/ 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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L Z- <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 Joaquii <br /> County Ordinance No. 1862 and the Rules .-and Regulations of the San Joaquin Local Health District. <br /> L�f <br /> 7- 0�(o -co l <br /> JOB ADDRESS/LOCATION BRENNEN RD. # 2 WELL <br /> CENSUS TRACT <br /> Owner's Name PHILLIP CHINCHILO & SONS Phone 982-0344 <br /> k Address 20548 E. RIVER RD. _ City RIPON, CAL. - <br /> Contractor's Name HENNINGS BROS. DRILLING COL INC. License # 116322 Phon622- 643 <br /> k <br /> 1 <br /> ,TYPE OF WORK (Check) : NEW WELL /_J DEEPEN /`7 RECONDITION /-7 DESTRUCTION /'7 _ <br /> PUMP INSTALLATION / PUMP REPAIR / pUMp REPLACEMENT /_ <br /> Other / / - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USES <br /> TYPE Of WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. - Dia. of Well Excavation 24"_ <br /> Domestic/private Drilled Dia, of Well Casing ] <br /> ' of <br /> Domestic/public Driven Gauge of Casingrr -. <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> k X� Rotary Type of Grout �r <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done7Z— <br /> PUMP REPAIR: / / State Work Done <br /> JDESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i <br /> P 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 <br /> SIGNED <br /> TITLE C <br /> �FOR <br /> PLOT P��WONTREVE, SE SIDE T <br /> D NUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II OUT INSPECTION <br /> PMj3, <br /> ION <br /> INSPECTION BY DATE INSPECTS BY g <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 lM <br />'k V <br />