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JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;OFFICE US§: 1602 E. Hazelton=Ave ;'"Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �&J <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance .No. 1862 and the.Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION3G S � � <br /> F _QEDAR RDc ,EAST CENSUS TRACT <br />' w <br /> Owner's Name MR . MARIE GARINO SIDEPhone , 599-3694 <br /> E Address <br /> .WAGNE RD. City ' RIPEN <br /> Contractor's Name GBRO . DRILLING CO. ,INC . License U.290813 081 Phone 522-1 0 31 <br /> 00 W. RUMBLE RD. MOD . <br /> TYPE OF WORK (Check): NEW WELL /K7 DEEPEN 'L-7 /7 DESTRUCTION /-'j <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT <br /> Other <br /> f r <br /> .DISTANCE TO NEAREST: SEPTIC ;'TANKSEWER LINES PIT PRIVYjq�_ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHHR f <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL' " <br /> INTENDED DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;r Cable Tool' Dia. of Well Excavation 2211. <br /> Domestic/:private . .Dri.11ed _Dia__,,�of�.W <br /> ell <br /> �_ —w :..... ...� <br /> Domestic%publicDriven <br /> Gauge of Casing <br /> X Irrigation Gravel Pack _ Depth of. Grout Seal <br /> Cathodic Protection IX Rotary Type 'of-Grout- <br /> Disposal r Other Other In€ormation 'L14AB_BY_OWNED_ <br /> Geophysical Surface Seal Installed By: <br />� PUMP 'iNSTALLATIONa Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />�PUM REPAIR ­/7—S ta te Work Dobe <br />; DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> TT 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 therm before putting. the..well in.use... -The above <br />', information is true to- the-best-o£ my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A PINAL.1,INSPECTION.. <br /> SIGNED. BENNINGS BROS . DRILLINU qU. 9INC. -- BY TITLE SEC4& <br /> DRAW PLOT PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION' ACCEPTED BY f DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA II AL INSPECTIQN <br />' INSPECTION BY J= DATE INSPECTION BY DATE <br /> E H 1426 Rev. "1-74 Y �� `j 1./arc oar <br />