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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOV OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r­_ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.JAZ--/��[�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /r d7z-J <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 /> 2ry 7- oil o D Z <br /> JOB ADDRESS/LOCATION BRENNEN RD. - # 5 WELL CENSUS TRACT <br /> Owner's Name PHILLIP CHINCHILO & SONS Phone 982-.0344 <br /> Address 20848 E. RIVER RD. City RIPON, CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License #11_b322 Phone 522_564.3 <br /> I TYPE OF WORK (Check) : NEW WELL /X DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> ' PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /_7 <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 24rr <br /> Domestic/private Drilled Dia. of Well Casing 1611__ �O <br /> Domestic/public Driven Gauge of Casing iT <br /> -_-X Irrigation Gravel Pack Depth of Grout Seal. <br /> Other X Rotary Type of Grout <br /> f Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT- / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> :.RESTRUCTION OF WELL: Well Diameter 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 /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> t 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. <br /> SIGNED ` TITLE <br /> ' DRA PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> } APPLICATION ACCEPTED BY ATE �2� J <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAdJEJ(114 IAL INSPECTION <br /> INSPECTION BY DATE INSPECT ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />