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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit' No. ?6-1 7 Sld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 14-S`76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sass 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 <br /> Rules and Regulations of the San -Joaquin Local health District. <br /> JOS ADDRESS/LOCATION (D �na kle R CENSUS TRACT <br /> Owner's Name LLOYD. BARTON Phone 599-3898 . ...� <br /> Address 25031 S. MC HLER RD. City ' RIPON <br /> Contractor's Name HENNINGS BROS. DRILLING COL INC. License # 290813 Phone .522-1031 <br /> ==01=�­2300 W. RUMBLE RD. MOD. <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/-' RECONDITION %j DESTRUCTION /_7 <br /> PUMP INSTALLATION-N/ / PUMP REPAIR/? PUNP REPLACEMENT F <br /> Other j/% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY QQ ,, <br /> SEWAGE DISPOSAL I�FIELD CESSPOOL/SEEPAGE PIT OTHER V. <br /> PROPERTY LINE 0P�'RIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation ►� <br /> Y„ Domestic/private Drilled Dia. of Well Casing b.- n' <br /> Domestic/public Driven Gauge of Casing 12 GAV <br /> Irrigation Gravel Pack Depth of Grout Seal 01 <br /> Cathodic Protection X- Rotary Type of Grout Bentonite <br /> Disposal Other Other Information 9 1�kowne r <br /> t <br /> Geophysical Surface Seal. Installed BY: ' driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..we11. in.use.,,. 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 INSPECTION. <br /> SIGNED N I GS B INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: All <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY TE 7;; <br /> O-�N BY <br /> DATE <br /> 7J6 Rv. 1-74 <br /> 4/75_ 2M <br />