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{ �jJ SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOFaOFF.IC.E U� SE / " j1601. E. .Hazelton Ave. , ,Stockton, Calif. <br /> r Telephones (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> r � <br /> (Complete In Triplicate) <br /> Application is Ae reby 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 and1the Rules and-Regulations of t e San Joaquin Local Health District. <br /> .I/WV S'" <br /> Y . <br /> r` he <br /> JOB ADDRESS/LOCATION Nu " 13d.. <br /> p le So. of River Rd. CENSUS TRACT i <br /> Owner's Name Mary Pope Phone 599- 707` , <br /> Address 21991 30j," Murphy Murphy Rd. <br /> 4 City Ripon, Ca1. '95366; <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc: License d1290813 phone 51+ -1115 i <br /> { <br /> ---3525 Pelandale Ave. Modesto_,„ Calif. 25350 <br /> TYPE OF WORK (Check) : NEW WELL _DEEPEN /_% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /, /� PUMP ,REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _12_5 SEWER LI PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY]LINE - PRIVAT DOMESTIC WELL ZL� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well,/Excavation <br /> (� Domestic/private C Drilled Dia. of WeIP'Casing, w_ - <br /> t <br /> 'Domestic/.publ:ic— —DrivenGau a of Casxn <br /> Irrigation 1 Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection � a Rotary Type of Grout Benonite <br /> DisposalI Other Other Informationfilajj3r � r_ <br /> Geophysical j _Surface Seal Ins&Med By:";\ nr; j,6r <br /> PUMP INSTALLATION: Contractor , (,c1 -f 17 <br /> Type of Pump, a I H.P. <br /> PUMP REPLACEMENT; / / State Work Done .f''} ss�;� s <br /> PUMP :REPAIR• �� }_ • �� <br /> / / State Work Done <br /> ' 1 C <br /> DESTRUCT WEL1,: Well Diameter � � 5U{ s.� Appioximate Depth <br /> escrib'e Material an PC/ Ced'ure i <br /> I hereby agree to comply with all lawg and regulati ns of the n Joaquin L cal Health District <br /> and the State of -California pertaining to or regulating-Vel 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 .well in-use. . The above <br /> information is true to the best of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. .�`_ . . <br /> SIGNED HEN INGS BRUS. D I . , .INC. TITLE B <br /> (DRAW PLOT FLAN.. ON REVERSE SIDE) <br /> F9W DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED.BY__ DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASZ41k, G OUT JNSPECTION PHA II FIN IN PECTIO <br /> INSPECTION BY DATE s INSPECTION BY DATE <br /> E H'1426 Rev. 1-7L 133-1 G.ja aj1 it n _ 1177- - 2M J� <br />