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SAN JO JIi'-LOCAL HEALTH WISTRIGT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS AOCATION 20035 East Mello°.-' ,.-,� CENSUS TRACT <br /> Owner's Name Charles Sinarle Phone ' 599-3797 <br /> Address 20035 East Mello City . Ripon, Cal <br /> Contractor's Name Hennings Bros . Drilling Co. Inc. License #290813 phone '522-1031 . <br /> 2 00 West Rumble o esto, Cal. 95350 <br /> TYPE OF WORK (Check) : NEW WELL /XT DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 i <br /> PUMPrINSfALLATION / / PUMP REPAIR :/� PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 60,t SEWER LIKES PIT-PRIVY_ <br /> SEWAGE DISPOSAL FIELD- CESSPOOL/SEEPAGE PIT `` OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC,WELL.' PUBLIC DOMESTIC WELLO t <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ,' Dia. of Well. Excavation list � <br /> X Domestic/private Drilled Dia. of:Yell Casing 61, Plas ti c W <br /> Domestic/public Driven r' s Gauge'of Casing 160W <br /> Irrigation Gravel Pack ; _ Depth of Grout Seal 01 <br /> Cathodic Protection X X . Rotary Type of Grout Bentonite . <br /> Disposal Other Other Information- , Siat 157 awnui <br /> Geophysical Surface Seal Installed B Driller <br /> PUMP INSTALLATION: Contractor <br /> Type .of .Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 'REPAIR: / / State 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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well. in.sise.... 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 FI AL INSPECTION. <br /> SIGNED TITLE - <br /> PLAN ON REVERSE SIDE <br /> DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY 0007, <br /> DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHOW I INSPECTI N PHAS SPECTIO <br /> INSPECTl;ON BY DATE A INSPECTION B TE <br /> ~Wass +��-fly r �t R 1pe1 ° <br /> h775 2M <br />