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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£i:OFFICE USE: 1601 E. Hazelton'Ave. , 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 'Wa' de 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 /> JOB ADDRESS/LOCATION. 20309 E. RIVER .RD.-BETWEEN CARROLTOY-& CENSUS TRACT <br /> VAN ALLEN RDS . NORTH SIDE,. . <br /> Owner'e-Name G.F. D ILLEY . `- Phone' " 02 <br /> Address 20-30f E. RIVER RD. City RIPON _. <br />` Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 2 083 Phone 522 ����1 <br /> f 2 00 W. RUMBLE RD. MOD. <br /> � � <br /> TYPE OF WORK (Check): NEW WELLIV DEEP ' -7 RECONDITION %j DESTRUCTION /_7PUMP INSTALLATION I / PUMP REPAIR'/? PUMP REPLACEMENT- /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '312 PUBLIC DOMESTIC WELL O ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W' <br /> Industrial Cable Tool, Dia. of Well `Excavation n x• ®� <br /> X _ Domestic/private a Drilled Dia. of Well Casing 61t <br /> Domestic <br /> /public Driven Gauge of Casing Wn <br /> Ix.rigation14 Gravel Pack Depth of Grout Seal _ . <br /> Cathodic Protection _ Rotary Type of Grout :, <br /> Disposal Other Other Information ' <br /> - <br /> Geophysical Surface Seal Installed 'B : ' <br /> PUMP INSTALLATION: Contractor " . <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: , / l State Work Done <br /> PUMP :REPAIR. <br /> /? :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe, Material. an Proce re <br /> I hereby agree to complyswith- ail iYaws and regulations of the an Joaquin Local Health District 1 <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 FORA -GROUT INSPECTION44 <br /> PRIOR TO GROUTING AND A FINAL -I-NSPECTION, <br /> SIGNED HEN GS R S. . INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II WUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DTE INSPECTION BY DATE <br /> 911"1426 <br /> Rev. l :.... <br /> r <br /> --74 1' ' h/79 2M s <br />