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f <br /> / w4em4'.r '70 <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT 14h <br /> SOF OFFICE USE: f/ 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-67811 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PM-17 <br /> No. <br /> 11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/21 <br /> (Complete in Triplicate) <br /> Application is $ereby made tofthe Sgn Joaquin Local Health District for a permit to construct• <br /> and/or install the work h�erei,n described. This application is made in Compliance with San Joaquin, <br />{ Re a ops of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and -the Rules an <br /> Aw- <br /> JOB ADDRESS/LOCATION one-�fo�.rth mile Softh flf H 120. TnterseCtiMSUS TRACT <br /> Owner's Name <br /> Mrs. Ory `Henry and Charles Hari-lea Phone 5993991 ` <br /> Cal <br /> 'Address 18404 S• H� Ripon Rd a City Ri.pon� <br /> Henngs Bros, Drilling CO.� Inc. License 290$13 Phone 55-11 <br /> Contractor's Name a 9�3 5 <br /> e an a e ve. esto a z <br /> TYPE OF WORK (Check): -NEW WE DEEPEN / / 'RECONDITION -/_7 E LACION <br /> EMELI17 <br /> P INSTALLATION / /. <br /> PUMP REPAIR'/� <br /> ,., . UMP <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 00 +SEWER LINES 100 *PIT PRIVY +" <br /> SEWAGE DISPOSAL FIELD may' . CESSPOOL/SEEPAGE PIT OTHER <br /> PR6PERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> �I INTENDED USE TYPE OF WELL! v * CONSTRUCTION SPECIFICATIONS 24n a <br /> Industrial. ,a_-•I Cable Tool Dia. of Well Excavation ; <br /> }� Domestic/private ` ^t R Drilled '`-Dia. of Well Casing 1 tt n <br /> Domestic/public t � Driven "� Gauge of Casing <br /> X Irrigation Sty Gravel Pack Depth of Grout Seal <br /> i Protectio g. Rotary Type of .Grout <br /> Cathodic +7 Other'Itiformation a OWner <br /> Disposal f Other , <br /> Geophysical } +�. Suxface Seal Installed BY: � • <br /> PUt� INSTALLATION: Contractor H.p. <br /> Type of Pump •' <br /> I PUMP REPLACEMENT: / / State Work Done . <br /> PUMP :REPAIR: A-7. <br /> .,State Work Done <br /> I ` DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> l Describe Material and Procedure <br /> I 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 oftthe 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 C44LL FOR A GROUT INSPECTION <br /> ( PRIOR TO GROUTING AND A �INAL 'INSPECTION. <br /> SIGNED enn�ngs nos. r2 Ing Go., Inc. TITLE <br /> (DRAW PLOT TLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' DATEf 7 <br /> APPLICATION ACCEPTED BY i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT( H <br /> DATE INSPECTION BY <br /> INSPECTION BY <br /> _E H 1426 Rev 7 . <br />