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sU v = ,SAN JOAQUIN 1OCAL HEALTH DISTRICT <br /> FOR,-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7 <br /> -5;2 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3d <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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i JOB ADDRESS/LOCATION2 LAI RTVPg RD.-BETWEEN CARROLTON & VAN AL' IJMSUS TRACT , <br /> f NORTH SIDE <br /> 1 . Owner's Name EL-R. Y FREDERICKQ Phone 7 <br /> - 0 0 <br /> 3 <br /> Address 2 . RIVER RD. City RIPON <br /> i.. - <br /> Contractor's NameLicense 290813 Phone - 522-1031 <br /> HENNING�S_ EROS. DRILLING C0.•,INC. <br /> O1-W RUMBLE RD. , MOD: <br /> TYPE OF WORK (Check) : NEW WELL A-7 DEEPEN '/7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/-7PUMP REPLACEMENT /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK -'f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER akl/- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE �, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` i Cable Tool Dia. of Well Excavation 1111 <br /> X _ Domestic/private Drilled Dia. of Well Casing b" PLASTIC <br /> Domestic/public Driven Gauge of Casing - 60 Wall Pf Z <br /> Irrigation Gravel Pack Depth.of Grout Seal 50' <br /> Cathodic Protection X Rotary _ Y <br /> f Type of GroutBentoniteDisposal Other <br /> •" •"•'" <br /> Other Information ' Slab- by-dimer <br /> Geophysical i Surface Seal 'Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /. / State Work Done <br /> DESTRUCTION 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- myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BBW. DRR LL11M 9 INC. BY TITLE SEC a <br /> Ij: (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , . <br /> JA <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �M <br /> P II 0 INSPECTI N PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y70 4 <br /> E H 1426 Rev. 1-74I� �/ l L/75 2M <br />