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FOEfOFFICE`'USE.­ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �i1601 E. Hazelton Ave. , Stockton, Calif. <br /> { <br /> 1} - Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 24�; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 3 lR�� <br />�. APPlication is hereby made t� p <br /> the San Locallete In Triplicate) <br /> and/or install the work herein described. This application Dis 'ma.de inistrict rcompliance a permit twithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> D M PT) CENSUS TRACT <br /> Owner's Name NORTH SIDE <br /> I.R. RT3IZ <br /> Phone 599-4875 <br /> Address b E RIVER RD.. <br /> City RIPON <br /> Contractor's Name 'HENNINGS BROS. DRILLING CO, <br /> INC. License # 290813 Phone 522-1031 <br /> 2500 W; RUMBLE D. MUD* <br /> TYPE OF WORK (Check)': NEW WELL <br /> /Y/ DEEPEN '/—/ RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK j <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER `r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT PUBLIC DOMESTICWELL \ <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS ' <br /> Cable Tool Dia. of Well Excavation 11 -3 <br /> X} Domestic/private <br />—7— Drilled Dia. of Well Casing- r' last$cw ;__._ <br /> Irrigation ` 1 Gauge'of"Casing "" 0 wall <br /> rf } Gravel Pack Depth of Grout Seal Qt <br /> w Cathodic Protection X Rotary Type of Grout Bexitori to <br /> Disposal I Other <br /> Geophysical Other Information S a - y owner <br /> - � Surface Seal Installed B : driller ;f <br /> PUMP. INSTALLATION: <br /> Contractor <br /> Type ofl' Pump <br /> r H.P. <br />'UMP REPLACEMENT: ' e. <br /> State Worts Done <br /> j. <br /> UMP '.REPAIR: / / State Works Done t <br /> ? <br />'ESTRUCT'TON OF WELL: Well Diameter •" �- / <br /> Approximate Depth <br /> Describe' Ma erial and Procediar <br /> hereby agree to comply with all 1 s and regu at ' ns of the S Joaquin L cal Health District { <br /> nfl the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> TILfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> L DRILLERS REPORT of the well and notify them before <br /> putting the well in use. <br /> reformation is true to the bestlo - my knowledge and belief. I WILL CALL FOR A GROUT eabove <br /> INSPECTION <br /> 3IOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED HENNINGS BR OS. DR INC . BYx <br /> TITLE SEC <br /> , ,. . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'IASE�I FOR EPARTMENT USE ONLY <br />?PLICATION ACCEPTED BY C� { <br />)DITIONAL COMMENTS-. DATE �, k <br /> E PHASE Ll GROUT INSPECTION PHASE III/ NAL INSPECTION <br /> JSPECTION BY DATE -�� --7 7 INSPECTION BY ,✓ DATE k <br /> E H 1.426RevJ 1� 74 /•2 2- Oe/D T/`f c� GvFC�.� 1 E77 oar <br />