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M1 PSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) x+66-6781 Permit No. 7 7- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' <br /> FROM DATE ISSUED Date Issued77 <br /> . THIS PERMIT EXPIRES l YEAR F � <br /> (Complete In Triplicate) <br /> Application is hereby made toithe San Joaquin Local Health Distmade inrict rco pliancea permit twith nSan uJoaquin I: <br /> and/or install the work herein described. This application <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin L2_jwl H3aUS District. <br /> 4 S ENSUS TRACT <br /> 74tOC <br /> JOB ADDRESS/LOCATION-JACKTONE RD-nlMZLE NORTH OFWE N5IDIS RD. <br /> I Phone 599-3896 <br /> Owner's Name ART VAN GRONINGEN <br /> ! city RIPON <br /> Address . 13799 CLINTON SOIITH <br /> Contractor's Name HENNINGS I BROS. DRILLING' COL INC'. License # 290813 phone <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN / RECONDITION /PEPLACEMENT�I�T 6 <br /> PUMPI INSTALLATION I 1 PUMP REPAIR I 1 <br /> Other / J <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' : TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of Well Excavation 2�+1e <br /> Domestic/Private Drilled Dia. of Well Casing <br /> Driven. Gauge of Casing GA <br /> °Domestic/public :. Gravel <br /> Pack Depth of Grout Sealrrigation T e of GroutCathodic Protection �_ Rotary yP WD <br /> Disposal Other _� Other Information S ab-b_ <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contactor H.F. <br /> j Typed of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> t - Approximate Depth <br /> DyESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 11 <br /> o comply with all laws and regulations <br /> hereby a ree tlations of the San Joaquin Local Health District <br /> =i he y g <br /> EEN DAYS <br /> and the State of California pertaining to oZ regulating <br /> egulwill ting well" <br /> the cSan t,Toaquin'Local hHealthDistrict � <br /> in use. above <br /> District <br /> after completion of my work on a new , <br /> WELL DRILLERS REPORT of the We1lof my nknowledgethem <br /> andbefore <br /> belief. I WILL CALL FOR A GROUTeINSPECTION <br /> ► information is true to the best <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. BY TITLE EC. <br /> SIGNED HENNINGS BROS. 1DRILLING CO. INC- <br /> D . W PL T PLAN ON RE FRSE SIDE) <br /> F DEP TMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION `ACCEPTED ..BY <br /> ADDITIONAL COMMENTS: P S /FIN INSPECTION <br /> PHAS GROU INSPECTION TE _ <br /> -77 <br /> INSPECTION BY <br /> DATE INSPECTION <br /> 3/76 2M <br /> � <br /> vL-_ _ S <br /> E H 1426 R` ev• 1~74 <br />