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dsY - <br /> SAJ:FOE.flFFICE USE; `J91OUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate.) <br /> Application is hereby -made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0n 2 -Mile South of West Rippon CENSUS TRACT -'2-57-020-03! <br /> Owner's Nance Tony Dttra 823--x.$36 <br /> Phone <br /> Address 5496 E. West Ripon Rd. City , Manteca � <br /> Contractor's Name Hennings Bros . Drilling Co. ,Ina'. License # 290813 hone . 622-1031 i <br /> 2500 West Rumble a es o, alifornia� . <br /> f <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION /7 DESTRUCTION f_7 ' <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7-pump REPLACEMENT /7 �lf <br /> Other /% . . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <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 2411 <br /> Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i <br /> 8 � Gravel Pack Depth of Grout .Seal <br /> Cathodic Protection XIX Rotary Type of Grout <br /> Disposal Other Other Information Slab by—owner—'— <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type .of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: . j_/ State Work Done <br /> .. 1 <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 -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 G OUTING ANDA VININSPECTION. t <br /> SIGNED TITL GLS <br /> (DRAV PLOT- PLAN ON REVERSE S I <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE4ILj� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III F AL INSPECTIO <br /> INSPECTIONBY DATE INSPECTION BY ZV <br /> 401204 <br /> F H 7A7A n.... I_'7A <br />