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/e / , . <br /> / <br /> `� SAN. JOAQUIPi LOCAL HEALTH DISTRICT ' <br /> FO7OFFICE USE: 1601 E. Hazelton Ave; , Stockton, Calif. <br /> Telephone: (209). 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �1F1W <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued <br /> (Complete In Triplicate) — <br /> Application is hereby made to the San Joaquin Local 'flealth District for a, permit toconstruct <br /> sand/or install the work herein described. This application is ,arcade in compliance with San Joaquin <br /> County Ordinance Na. 1862 and' tbe. Rules and Regulations of. the San• Joagyin Local Health District. <br /> JOB ADDRESS/LOCATION 2222 N_R1 nnj3 RSI".-�-mi North-_Q .M1.1geo Rd.,, CENSUS TRACT: <br /> east -side. <br /> Owner's Name- Francis Groep F Phone ' 599-6619' <br /> Cit Ri-0on <br /> Address 22752 N. Ripon Rd.-- --- y -- _ <br /> Contractor's Name Henning - Bros., Drillin Col, Inc. License VR2 081 -Thome . 522-1011 <br /> 2500 W. Rumble Rd. . Modesto <br /> t <br /> TYPE OF WORK (Check): NEW WELL /37 DEEPEN '/7 RECONDITION f7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION/ / PUMPREPAIR I PUMP REPLACEMENT /7 a <br /> Other 1/% <br /> DISTANCE TO NEAREST: ' SEPTIC� TANK ZM SEWER LINES PIT PRIVY ¢.1 <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERi, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . � . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable•Tool Dia, of Well Excavation G` <br /> X Domestic/private Drilled Dia. of Well Casing ,_ 6--5/8" <br /> Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack' Depth of Grout Seal 50; _ <br /> Cathodic Pr_otect__ion X Rotary Type of Grout Bentonite - <br /> Disposal Other Other Information ' ' Slab- by 'owner . <br /> Geophysical 4 Surface Seal Installed BX: driller 9p�� <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done 1 <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 Sari 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 CALL FOR,A ,GROUT INSPECTION <br /> ' PRIOR TO GROUTING 'AND A'FINAL INSPECTION. <br /> SIGNED HeLmings Bros. Drilling Co. Inc. by TITLE See. <br /> r DRAW PLOT PLAN ON REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE G' <br /> ADDITIONAL COMMENTS: <br /> ' PHASE 1.1 GROUT INSPECTION ' P II INSPECTI <br /> x�gPECTION BY DATE s: 5" y INSPECTION .BY DATE <br /> 14- EI <br /> 1426 Rev. 1-74 5-f5? 3 y S-I-. /75 2M - <br />