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t .._. I .y, 1. I• <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT ; <br /> FOE OFFICE USE: jl 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z/SF'A/ <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued µ-77 <br /> T 7 <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 workfherein 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 20865 E. RIVER _RD.-5001 WEST DE VAN AT,T,RN_Rf)ENS US TRACT <br /> ,fM NORTH .SIDE <br /> Owner's Name Tpny_Van Dorst —-- _ _ Phone <br /> I2. _ Cit RIPON <br /> Address ��2056 E. RIVER RD. Y ; <br /> I�. s <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 29Q813 Phone <br /> 2 00,. W. RUMBLE RD. , MOD. _ <br /> TYPE-OF.-WORK `(Cheek):: ' NEW;WELL 1-jf t-DEEPEN-;/--/--,RECONDITION'/777'" DESTRUCTIONS'/? : - <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK 750 7 SEWER LINES _;rg PTT PRIVY <br /> SEWAGE DISPOSAL FIELD7Y0 CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL . "PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Rr. <br /> Industrial Cable Tool Dia. of Well Excavation _ 11s" <br /> Domestic/private Drilled Dia, of Well Casing _-p le <br /> Doo est a/public -' .Driven`J" `" `�Gaug of`Casin`g - ` - <br /> X Irrigation X Gravel Pack Depth of Grout Seal (y <br /> Cathodic Protection X Rotary Type of Grout <br /> — <br /> Disposal f Other Other Information SB-BY OWNER <br /> Geophysical M Surface Seal Installed By: A <br /> III <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump v . H.P. 1S <br /> PUMP REPLACEMENT: / State !Work Done <br /> PUMP REPAIR:, / State Work Done f <br /> DES-TRUCTION 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 /> i and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my .`aork 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 GR TING AOD AMF IN ECTION. ' <br /> SIGN TITLE <br /> iz �I DRAW'PL TPLAN 'ON REVERSE SIDE <br /> E FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY,` DATE <br /> F ADDITIONAL COMMENTS: �!. <br /> PHASE II GROUT INSPECTION PHAStIIIOININSPECTIQN <br /> INSPECTION BY .... 141 DATE INSPECTION BY OVIDATE 3 3 <br /> �¢ .. 3/76 2M <br /> k E H 1426 Rev. '1-74 t ' aR 10 <br />