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I� �T -70 0r,&*_6R-1 <br /> ✓ SAN JOAQUIN LOCAL. HEALTH DISTRICT A4,AI'L <br /> �Oh OFFICE USE: ' i 1601 E. Hazelton Ave. , ,Stockton, Calif. t"X5 <br /> Telephone: (209) 466-6781 -77J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/2 '77 <br /> (Complete In Triplicate) <br /> Application is Aereby made toIthe 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 OrdiOf <br /> nance No. 1862 and 'the Rules an Regulat'o s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIbN one-fourth mile Sodth of H 120 Intersectimsus TRACT <br /> i ' <br /> y ` <br /> Owner's Name Mrs.. Mry .Henn - and Charles Hari-As Phone 5 99-3 991 <br /> 'Address 18404 S. N. Ripon Rd. City - Ripon, Cal <br /> �I <br /> Hennings Bros. Drilling Co. , Inc. License # 290$13 Phone 545-118 <br /> Contractor's Name .� <br /> e an a e Aire. Modesto, Cal. 95350 <br /> i <br /> TYPE OF WORK (Check) : -NEW WELL X-1DEEPEN / / 4RECONDITION '/ / DESTRUCTION /'7 <br /> } PUMP INSTALLATION /—/,—PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 400 +SEWER LINES 400 #SPIT PRIVY .• <br /> SEWAGE DISPOSAL FIELD 4- . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, V * CONSTRUCTION SPECIFICATIONS <br /> Industrial. II °'°'.1 Cable Tool Dia. of Well Excavation 24tt <br />�. Domestic/private "IX Drilled ,,Dia. of Well Casing l tt <br /> Domestic/public IDriven Gauge of Casing 3/16" <br /> X Irrigation ` i Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection . X. Rotary Type of Grout <br /> Disposal Other Other'Information Slab by owner <br /> Geophysical Surface .Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> L <br /> PUMP REPLACEMENT: L/ . State Work Done <br /> PUMP .REPAIR: A / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j 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 offthe 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 CAJL FOR A GROUT INSPECTION <br /> ! PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED flennings °'I nos . riing Go., Inc. TITLE / <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I, I <br /> PHASE II GROUT INSPECTION PHASE III ,FINAL INSPECTI N / <br /> INSPECTION BY l� DATE INSPECTION BY G,/ DATE /,ff �7(� <br /> �a 4 Nay <br /> ��E H 1426 Rev. 1-.74 _ Z <br />