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KV U <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160'` Hazelton Ave, , Stockton, Cal_ f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L2 9yIJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , to I <br /> (Complete In Triplicate) <br /> f <br /> Application is .hereby made to the San Joaquin Local Health District foit n truct <br /> This application is made in compliance with San Joaquin <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District': <br /> JOB ADDRESS/LOCATION 21205 South Wagner 1/2 Mile S. of Me11 r <br /> �ENSUS TRACT <br /> i <br /> I <br /> Owner.'s Name Ted Viss Phone 599-6691 <br /> Address 21205 So. Wagner <br /> City Ripon, Cal, <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc. License #29013 Phone 522-1031 <br /> 2 00 West Rumble Rd. Modesto Cal, 95350 <br /> TYPE OF WORK (Check): NEW WELL /-V DEEPEN /_/ RECONDITION <br /> _/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2501 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11" <br /> X Domestic/private Drilled Dia. of Well Casing 611 Plastic <br /> Domestic/public Driven Gauge of Casing 160 W <br /> Irrigation Gravel Pack Depth of Grout Seal 50 t Seal _ <br /> Cathodic Protection - Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Blab by owner <br /> Geophysical Surface Seal Installed By: Driller' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work D4z 0 <br /> ne <br /> DESTRUCTION OF WELL: Well CameterApproximate Depth <br /> Describe Material and Proc dure <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'� I <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 L FOR A GROUT INSPECTION t <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED DFULLING CO. , INC . TITLE KPR <br /> -�,.(DRAW PMT PLAN 'ON RE FRSE SIDE} <br /> PHASE I <br /> FOR <br /> EP MENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE TII/ N NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY !r DATE <br /> E H 1426 !�!R' ,i' ,�, / p�S ! / ;� �r, `z, <br /> Rev. 1-74. f. i 3�7b 2M <br />