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SAN JOAQUIN LOCAL HEALTH- DISTRICT } <br /> FOF'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 1330 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 />'E JOB ADDRESS/LOCATION RIVER RD--2ND I�TAT�,BOX EAST_ OF WAGNER RD.- CENSUS TRACT <br /> i w SOUTH SIDE <br />!, Owner's Name ALLEN RANCH CHUCK MIDDLETON Phone <br /> Address 18700 E. RIVER RD. City RIPON <br /> Contractor's Name HENNINGS BROS. 'DRILLING CO.. jNC . License # J2 081 Phone ' 522-1011 <br /> 2500 W. RUMBLE RD. , MOD-. <br /> L; <br /> E TYPE OF WORK (Check) : NEW-�WELL /X/ DEEPEN /_/ RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ J PUMP REPAIR / J PUMP REPLACEMENT /-J <br />€ ! _ Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK a&n SEWER LINES I&Vp PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD OUA CESSPOOL/SEEPAGE PIT OTHER,O*jb-7O�� i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED, USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia, of Well Excavation _ 2Lpi - <br /> Domestic/private Drilled Dia. of Well Casing 1� <br /> p g 16 ' <br /> ' Domestic/public Driven Gauge of Casing <br /> �T Irrigation X Gravel .Pack Depth of Grout Seal _ 44 ' <br /> Cathodic Protection X Rotary Type of Grout _ <br /> Disposal Other Other Inf ormation SLAB-BY OWNER <br /> Geophysical 7�(f 1 Surface Seal Installed By: .., <br /> f7 c <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> E PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> . Describe Material and Procedure <br /> 1 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 INSPECTION. <br /> SIGNED BENNINGS BROS. DRILLING C06-2INC. BY TITLE SEC <br /> DRAW PL T' PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE7111172 <br /> ADDITIONAL COMMENTS: <br /> r•, PHASE II GROUT INSPECTION PHA5,F4tt.TIjffFIAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY ,&l DATE <br /> I i <br /> E H 1426 Rev. 1-74 3/76 2M <br />