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SAN JOAQUIN"LOCA HEALTH DISTRICT -4,/ <br /> 4��FFICE 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 l YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> County Ordinance No. 1862 and the Rules and Regulations .of the San Joaquin Local Health District. ? <br /> 76 <br /> JOB ADDRESS/LOCATION TRAHERN RD & TWO RIVERS RD. CENSUS TRACT - <br /> Owner's Na.m6 PAUL KENNEDY Phone 599-222 ` <br /> Address 1017 7th St. City - Ripon, Cad. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License #290813 Phone "522-1031 <br /> West ft=tle Rd. , 1. 95350 <br /> TYPE OF WORK (Check): NEW WELL/TI_ DEEPEN '/? RECONDITION I_7 DESTRUCTION /_7 <br /> s <br /> PUMP INSTALLATION /J PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /56+ CESSPOOL/ AGE PIT OTHERS - Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL I#PUBLIC DOMESTIC WELL= <br /> INTENDED 'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. , <br /> Industrial Cable Tool Dia. of Well Excavation 12ti <br /> _X Domestic/private X Drilled Dia. of Well Casing ,? pias ti C <br /> Domestic/public. Driven Gauge of Casing <br /> .Irrigation Gravel Pack Depth of Grout Seal �ot <br /> Cathodic Protection X Rotary Type of GroutBentonite-Disposal Other <br /> Other Information Slab b, 4 owner <br /> Geophysical Surface Seal Installed B .,�... <br /> t <br />_PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP ,.RRPAIR: / / State Work Done <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' istrict <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 Logal 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 GROUTING AND A FINAL NSPECTION. <br /> S NED T i <br /> ( T, PLAN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ZZ2Z2 <br /> PHA§ PROPT INSPECTION PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE � � INSPECTION B ATE !9-- <br /> z?-� <br /> I Zf r �-� �lJ �a1= <br /> E H IA20; IDn­ 1_7A �' A/"7.7 2H i <br />