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SAN JOAQUIN LOCAL HEALTH DIST&IyM SIL V44M 1,r <br /> . <br /> r FOOFFICE USE-----I 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�I 7'/7 7D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ 2�'7J <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 Regular ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI N one-fourth mile Sodth of- Hwy 120 IntersectiMSUS TRACT <br /> — ozz the—rrgYrt std3TI <br /> Owner's Name _ Mrs• Mary Henry and Charles HarftsPhone 599-3991 <br /> Address 18404 S. N. Ripon Rd. _ _ City Ripon, Cal <br /> Contractor's Name Hennings Bros. Drilling Co., Inc. License 0 290813 Phone 545-118 <br /> --3375 Pelandale Ave. Modesto, a 95350 , <br /> TYPE OF WORK (Check): NEW WELL X7 DEEPEN /-7 RECONDITION /� DESTRUCTION - <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT rT <br /> Other <br /> DICTANCE TO NEAREST: SEPTIC TANK 400 t SEWER LINES 400 *PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPLRTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECiFiui:IONS j <br /> I Industrial Cable Tool Dia. of Well Excavation 2411 <br /> _ Domestic/private X Drilled Dia. of Well Casing 14" <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Deptii of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information "—owner <br /> Geophysical Surface Seal InstalledPUMP INSTALLATION: ContractorType of Pump <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMr REPAIR: / / Ststa Work Done _ <br /> DESTRUCTION 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 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 Joaqui^ 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 best of my knowledge and belief. L WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEC'.ION. <br /> SIGNED Rennings braS. UrIllIng Co., Inc. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDES <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> • APPLICATION ACCEPTED BY Z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE LII/FINAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION by / •'/ ..,DATE !� '•' � <br /> E H 1626 Rev. 1-74 <br /> Y . <br />