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a r 0. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ROF. OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 406-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br /> r (Complete In Triplicate) Z�5'-3 I 3 . <br /> Application is Aereby de to the San Joaquin Local Health District for a,permit to Coristruet 1 <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 Warren & River Rds. Dirt extension of CENSUS .T � S <br /> River Rdw pen <br /> Hoff_ZP1 - <br /> Owner's Name Beatrice Eckerson or..Henry Hoff & Son Phone 415-5 9 8-7096 <br /> Address 393 Palamor Ct. 22357 S0. 1darren Ave. San Bruno); Calif <br /> Ripon, Calif, City <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc* License U290813 Phone _ 522-1031 <br /> TYPE OF WORK (Check) : NEW WELL )r/- DEEPEN ./?. RECONDITION '/_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ./? <br /> Other / ] . <br /> DISTANCE TO NEAREST: SEPTIC TANK. 00 .SEWER LIMES k PIT PRIVY <br /> SEWAGE DISPOSAL FIELD t2? CESSPOOL/SEEPAGE PIT OTTER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _A_0 PUBLIC DOMESTIC WELL— <br /> INTENDED US$ TYPE OF WkLL CONSTRUCTION SPECIFICATIONS <br /> ndnstria _ Cable jQ0.1 of-Wei- Excavatln <br /> A <br /> ' A`Drilled Dia. of Well .Casing as. zC, <br /> Dcr4aestE/pxivaCe`. _ <br /> Domestic/publicDriven <br /> _ 'Gauge-of Casing` ` <br /> —� Gravelac <br /> Pk Depth of Grout Seal <br /> Ii��i:gaEion � . <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> DisposalOther Other Information slab_ by owher� .. <br /> ^Geophysical. Surface Seal Inst,all6d BY: Py <br /> PUMP INSTALLATION: Contractor 0 W1 <br /> Type of Pump <br /> H.P. <br /> "Hi1MP REPLACEMENT: j_/ State Work Done <br /> PUMP;REP,AIR:, / ] State Work Done <br /> DESTRUCTION`^ FYWELL: Well Diameter Approximate Depth <br /> A'�� Describe er'al and roc du e <br /> I her�by`­agreelto : Describe <br /> all, laws d regulations of the San Paquin LocA1 Health District <br /> and the`St _te. 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-s-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING PXD A ftNAL INSPECTION. <br /> SIGNED f TITLE G <br /> j (DRAW LO PLAN ON REVERSE SID <br /> OR DEPARTMENT USE ONLY - <br /> PHASE I - <br /> APPLICATION ACCEP ED BY �y _ DATEI I­ <br /> ADDITIONAL COMMENTS• <br /> P I ROT INSPECTIN PHASE III/ FINAL INSPECTION <br /> INSPECTION- DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-747 '""/ <br />