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SAN JOAQUIN LOCAL rALTH 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 �f-8 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/LOCATIONS ims Station - Behind Ripon Fire Dept. CENSUS TRACT <br /> Owner's Name Chinchiolo & Co. - 20048 E. River Rd. Ripon, CaPhone 982-03�4 <br /> Address HENNINGS BROS. DRILLING CO., City <br /> Contractor's Name 2500 W. RUMBLE ROAD License # 1 Phone 522-5,643MODESTO, CALIF. LICENSE 116322 <br /> TYPE OF WORK (Check) : NEW WELL /W, DEEPEN/ / RECONDITION /_� DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ u <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 <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 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. <br /> PUMP REPLACEMENT: / / State Work Done -7Z- LAlIVO-r— <br /> �E u rs 77 —p P Ro F" .�— <br /> PUMP REPAIR: / / State Work Done Wtr _ NE?T ��+9 e✓� .� <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth rYrd i <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 Distract a <br /> WELL DRILLERS REPORT of the well and notify thein before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED" . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7'7i <br /> ADDITIONAL COMMENTS: <br /> P OUT NSPECT N PHAS I INAL INSPEC N <br /> INSPECTION BY DATE 7- -- INSPECTION BY <br /> DATE r Z-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTI4G _AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />