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70B OFFICE USE: JOAQUIN LOCAL HEALTH DISTRIC` <br /> 160 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Date Issued 76 <br /> pPlication is hereby made to the San Triplicate)Joaquin Local health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joa us= <br /> 'ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> OB ADDRESS/LOCATION �p <br /> ' CENSUS TRACT <br /> owner's Name LLOYD BARTON <br /> Phone _ 8 8 <br /> f ddress 2 0 1 S. M0 HLER RD, <br /> City RIPON <br /> contractor's Name HENNINGS BROS . DRILLING COL INC <br /> 2 00 W. RUMBLE RD. MOD. • License 283 Phone 22-i 0 1 <br /> YPE OF WORK (Check): NEW WELL .97 DEEPEN '/? RECONDITION � E <br /> PUMP INSTALLATION -/ / PUMP REPAIR '/- PUMPREPLACEMENT�7 <br /> Other -- <br /> IS ICE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL/�FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE �+'1�RIVAT DOE MESTIC WELL' PUBLIC DOMESTIC WMEELL U <br /> INTENDED USE TYPE OF WELL <br /> Industrial , CONSTRUCTION SPECIFICATIONS <br /> X Domestic/private Cable Tool Dia. of Well Excavation 1 rr <br /> /private Drilled Dia. of Well Casing 6- rr <br /> Domestic/public _� Driven <br /> Irrigation Gauge of Casing 2 GA <br /> Cathodic Protection Gravel Pack Depth of Grout Seal O' <br /> _. - Rotary Type of Grout Bentonite <br /> Disposal Other _�� Other Information <br /> Geophysical 51ab-,..hk Owner <br /> Surface Seal Installed-By: driller <br /> UMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. . <br /> UMP REPLACEMENT: / / State Work Done <br /> '-- AR° State Work Done <br /> S•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Dept <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting.. the.-well in.use... .The above <br /> nformation is true to the-best of. my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ZIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED NNI GS R INC. BY <br /> TITLE4Z&L1LaSEC. <br /> {DRAW PLOT <br /> TON REVERSE SIDE <br /> BASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE l�71l, <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY TE PHASE III FINAL INSPECTION <br /> I PECTION BY <br /> �/C ay C�l � ; DATE <br />