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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> F'OFx*OFFICE USE: 1601 E. Haxeltbh Aver. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2C�` <br /> (Complete, ln 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 Regulations of the San -Joaquin Local Health District. <br /> fJOB ADDRESS/LOCATION 21801 South Jacktone CENSUS TRACT <br /> Work 599-4181 <br /> Owner's Name Cliff Eske's Phone Home 599-3321 <br /> Address 224 West ;Third St. City Ripon, Cal.. - <br /> Contractor's Name Hennings Bros. Drilling Co. � Inc., License # 290.813 Phone 522-1031 <br /> 2 00 West Rumble Ed. modesEol Calif. 9535 _ <br /> TYPE OF WORK (Check) : NEW WELL A DEEPEN '/? RECONDITION/ DESTRUCTION /� <br /> PUMP INSTALLATION / / Pu_mP:REPAIR-/� PUMP REPLACEMId 17 <br /> Other, / / . <br /> DISTANCE TO NEAREST: ve SEPTIC TANKti SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> PROPERTY LIA"' PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL N <br /> INTENDED USE ' TYPE:OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial-: !I ''. . it Cable Tool Dia. of Well Excavation; 1" <br /> x Domestic/private it : X-,Drilled Dia. of Well Casing 6-5/811 <br /> _ <br /> Domestic/public <R Driven 4 Gauge of Casing 12 ...._ <br /> Irrigation� i '`""""Gravel"Packr Depth of Grout Seal _ j 50l_ <br /> Cathodic Protection I X - Rotary s Type of Grout R�toriite <br /> Disposal i Other Other Informationogger <br /> Geophysical.: F Surface Seal Installed 'B e <br /> PUMP INSTALLATION-0- Contractor <br /> Type' o€ Pump H.P. <br /> PUMP REPLACEMENT, : R / / State Work Done # <br /> r <br /> :, PUMP-`.REPAIR: - / / State -Work"Don-e <br /> e <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> �. Describe Material and Procedure F <br /> I hereby agree to comply with. all-laws k-and'^regulations. of the San Joaquin -Local Health District <br /> and the State of California pertaining to or regulatingwell -'construction. Within FIFTEEN -DAYS <br /> after completion of my work on a new well, I will furnish1the .San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the iwell .and notify them before putting the..well. infuse.... The above <br /> information is true to the,best -of my.knowledge and belief. I WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR. TO GROUTING AND A FINAL INS PECT � �$ <br /> f SIGNED a Sri. s-Bro6. Dri 1 ng Co.._Inc. By,1. LTITLE- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Z <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS: `a <br /> r PHASE II GROUT INSPECTIONPIiAS MIFINAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY DATE _ -2 y2. <br /> F 14 .1IL76 Inv 7_7A s r' h/75- 2M - <br />