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SAN JOAQUIN LOCAL .HLTH DISTRICT # <br /> '0B OFFICE USE: 1601 E. Hazelton Aim;`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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for.. permit to Construct <br /> and/or install the work herein described. - `Thin application is aiade.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/LOCATION E., 1jjverjjdjL-.,_800' East of Carrolton Rd. : . ~ CENSUS TRACT.; <br /> 6001 Y. OF R Iger. e <br /> Owner's Name Ton Bruno Phone 9- 602 <br /> f .Address .1 97Z3 E River. Rd. . � City . . Ripon Y <br /> Contractor's Name ' - — ' . <br /> Hennings Bros: Drilling Co. , License # 290813Phone - 522-1031 <br /> 00 W. Rumble Rd., Mod. <br /> TYPE OF WORK (Check) NEW WELL /FDEEPEN /7 RECONDITION I7 DESTRUCTION f_7 <br /> PUMP INSTALLATION /� PUMP REPAIR-/-7—PUMP REPLACEMENT /'7 <br /> Other /:/ . # <br /> .DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINESr...Q_FIT PRIVY <br /> ^' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT R600 <br /> PROPERTY LINE - f PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 24+t <br /> Domestic/private Drilled Dia. of Well Casing 6n <br /> I Domestic/public Driven Gauge of Casing ] <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X - Rotary Type of Grout,' <br /> Disposal Other Other Info -- - <br /> rmation la o e <br /> Geophysical Surface Seal Installed B : . <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump B.P. <br /> • 4 <br /> PUMP REPLACEMENT: . C1 State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and regulations of .the San Joaquin Local Health District, <br /> trict, <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 th',e San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thea: before putting-the-.well in-use The above <br /> information is true to the-beat of-my knowledge and belief. I WILL CALL. -FOR A GROUT INSPECTION <br /> P,RIbR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED UNIJING S-BROS. DRILLING CO. INC. BY TITLE SEC-. <br /> DRAW-PLOT PLAN ON REVERSE SIDL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP ILP�CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHAN, II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E #I 1426 Rev. '1-74P <br />