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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUE-OFF10e, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP '1CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 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. 1W2 and the Rules and Regulat ionjs of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI1 K�0"C r W 1�7 a F ICi ( 1 12°Gr'm CENSUS TRACT <br /> Owner's Name Al Brocchini Farms Phone 599-4229 <br /> Address 27011 S. Austin Rd, City Ripon <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License # 290813 Phone 522-1031 <br /> 2500 We Rumble Ed,. , Mod, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL K/ DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK (SEWER LINES #qj - PIT PRIVY <br /> �J SEWAGE DISPOSAL FIELD CESSPOOL/$E�EPAGE PIT OTHER <br /> 7� PROPERTY LINE - PRIVATE DOMESTIC WELL N—P4( PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �1�n <br /> Domestic/private Drilled Dia. of Well Casing 16+; <br /> Domestic/public Driven Gauge of Casing 4-ru <br /> Irrigation X_ Gravel Pack Depth of Grout Seal -50t <br /> Cathodic Protection X Rotary Type of Grout Sgfce pipffCcemented in <br /> Disposal Other Other Information"- ter.. <br /> Geophysical Surface Seal Installed By: ,, dr litme <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done �l <br /> DESTRUCTION 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRI S REPORT of the well and notify them before putting the .well in use. The above <br /> inf orm4tion i ue to the-- e t of mynowledge and belief. I WILL CAIJ, FOA A GROUT INSPECTION <br /> PRIOR G G N SPE ON. <br /> SIGNED Z4—" <br /> D W 1L T PLAN ON REVERSE SIff V. <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE hI GROUT INSPECTION PHASE IIJ/FIN4 II/FININSPECTION <br /> INSPECTION BY DATE 22 INSPECTION BY DATE f=7 7 <br /> U ' <br /> E H 1426 Rev. 1-7� 3/76 2M <br />