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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE76FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-•6781 <br /> �S APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> 0 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7? <br /> Triplicate) <br /> In Tri 1 <br /> {Camlittc ! } <br /> Application, is, Agreby 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. 186 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2QJ 50 a. WILLIAMS AYEIT T OF AGNS • CENSUS .TRACT'. <br /> NORTH OF LLO-DIRT LANE, <br /> Owner"'s Name HENRYETIA HEKMAN 1Mi e ON EAST SIDE Phone 599-3297 <br /> Address . 20150 S WILLIAMS WAY City RIPON <br /> Contractor's Name HENNINGS BROS . DRILLING CO. INC e License 2 0$1 Phone 22-1'031 <br /> 2 00 <br /> W. RUMBLE RD. MOD. i <br /> TYPE OF WORK (Check) : NEW-WELL .U7 DEEPEN -/? RECONDITION /� 'DESTRUCTION /� . <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> 1 <br /> Other I / T <br /> DISTANCE TO NEAREST: SEPTIC TANK /20, SEWER LINES PIT PRIVY dIdwe-11 <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY- LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> IndustrialCable Tool, Dia. of Well Excavation 11 <br /> Domestic/private Drilled Dia. of Well Casing fy PLASTIC <br /> Domestic/public, _ .,.Driven Gauge .of. Casing_ 160 WALL <br /> Irrition. Gravel Pack Depth of Grout Seal <br /> ga0 a <br /> Cathodic Protection ---X Rotary Type of Grout BENTONITE , <br /> Disposal _- Other Other Information SLAIEBTOMMR <br /> Geophysical Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> t• _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 PUMP .REPAIR: /% State Work Done <br /> i.,DES.kWAN OF WELL: Well Diameter Approximate Depth <br /> I Des ribe terial aind P ocedure <br /> ' I hereby agree to comply with all laws regulation of the San aquin Local ealth District <br /> and the State of California pertaining to or regulating well 'cons ruction. Within FIFTEEN DAYS <br /> a€ter 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLIN CO. INC . . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> �RDEPAATMENT U5E ONLY <br /> iPHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> P GRO T INSPECTION PHASE /FIN NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /�" 6 7 <br /> , , <br />