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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOR.i FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.PC � <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 <br /> (Complete In Triplicate) L&D—/ 2— <br /> Application <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.zf1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> 23_(_ ,c 57__S_ . J y� I <br /> JOB ADDRESS/LOCATION _� 17 v p it v e'_' Blorth of -W, R J.Uan Rd. _ CENSUS TRACT <br /> Owner's Name Larry Wool Phone 529-2997 <br /> .k <br /> Address 23615 Olive Ave _ City Ripon <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. _ _ License # 29081,1 Phone 222-1031 . <br /> 2 500 W a Rumble Rd.o ,__Modesto ;, <br /> TYPE OF WORK (Check) : NEW WELL -/x DEEPEN ./-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 W <br /> DISTANCE TO NEAREST: SEPTIC TANK h0, SEWER LINES . <br /> FQ. PiT PRIVY { , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .ion A <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL ' 14-J_1 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool "Dia. of Well Excavation 1 s: <br /> X_ Domestic/private Drilled Dia. of Well Casing �f ! <br /> Domestic/public .Driven Gauge of Casing C• � <br /> Irrigation i Gravel Pack Depth of Grout Seal _Knl <br /> Cathodic Protection _ Rotary Type of Grout R Pn tnnitP i <br /> .Disposal Other Other Information Sla h- by owner <br /> Geophysical. �r Surface Seal Installed By: <br /> PUMP 'INSTALLATION: Contractor �-• <br /> Type.of Pump H.P. <br /> PUMP REPLACEMENT: •..- /% -State Work Done <br /> -PUMP-,,REPAIR: /_7 "State -Work Done`_ <br /> ES;'RUCTION 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 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 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A -FINAL IIJS PECTION. <br /> SIGNED TITLE <br /> ( ipWT PLAN ON ERSE SIDE ' <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: 71f J <br /> PHASE 11 MT I P TI � , PHASE. II/FINAL.-INSPECTION <br /> INSPECTION BY ATE' 3-L -7:-i .a INSPECTION BY . 4q___ _ DATE <br /> E ^H 1426 Rev. 1-74 '''' 1-74 2M - <br />