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+ r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.ZZ_1_5-Y d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11_A,2_72- <br /> (Complete <br /> 1A,2 72- <br /> (Complete In Triplicate) <br /> Pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .-ad/or install the work herein described. This application is made in compliance with San. Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F13B ADDRESS/LOCATION BRENNEN RD- #1 WELL CENSUS TRACT s <br /> �nervs Name PHILLIP CHINCHILO & SONS Phone 982-0344 <br /> `Address 20848 E. RIVER RD. RIPONI CALT ORNIA City RIPON <br /> �ntractor's Name HENIVINGS BROS. DRILLING CO. , INC. License # 116322 Phone 522-5643 <br /> FIPE OF WORK (Check) : NEW WELL /f/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other r_7 <br /> LCSTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 241r <br /> Domestic/private Drilled Dia. of Well Casing w Y� <br /> Domestic/public Driven Gauge of Casing ir$ <br /> I X Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout T <br /> Other Other Information <br /> ALME INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> FTMP REPAIR: / / State Work DoneX97.3 7. 7_1 i <br /> =. TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> �-fter 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 /> formation is true to the best of my knowledge and belief. <br /> f <br /> 4 <br /> SIGNED .43. TITLE <br /> r' OT PLAN ON REVERSE SIDE) _ <br /> �1 FOle DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B TDATE�� Z � <br /> )DITIONAL COMMENTS: <br /> 1`3 PHASE II GROUT INSPECTION P lium INSPECTION <br /> INSPECTION BY DATE INSPE�GT,I~ON BY TE <br /> CALL FO'R A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />