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ALD SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOR OFFICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 41,-, Telephone:: <br /> p (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k <br /> (Complete <br /> Application is hereby made to the SanJ'oaquin Lo al Health tDistrict for ae <br /> p rmit 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. - # 3 WELL CENSUS TRACT <br /> Owner's Name PHILLIP CHINCHILO & SONS <br /> i Phone 982-0344 <br /> k Address 20848 E. RIVER RD. city RIPON, CAL, <br /> f Contractor's Name HENg.,INGS BROS. DRILLING CO, , INC. License # 116322 Phone 522-5643 <br /> TYPE OF WORK (Check):. NEW WELL DEEPEN / / RECONDITION / / 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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation ri <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic et <br />� /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal E <br /> OtherRotar <br /> �_ y Type of Grout � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> i / / State Work Done <br /> JD <br /> ESTRUCTTON OF WELL: Well Diameter - <br /> 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 Dfstriet 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 myaknowledge and belief. <br /> SIGNED &j <br /> Of TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> PHASE T FOTMENT USE ONLY E <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY � P I` AL INSPECT N <br /> DATE INSPE --L0NB DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />