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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rAd/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> }g ADDRESS/LOCATION BRENNEN RD. - # 2 vMLL CENSUS TRACT <br /> Name PHILLIP CHINCHILO & SONS Phone 9$2-03 <br /> rnerls <br /> City <br /> RIPON, CAL. <br /> Address 20848 E. RIVER RD. <br /> Pntractor's Name HENNINGS BROS. DRILLING COL INC. License # 116322 Phone522-5643__ <br /> rPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other <br /> � ,ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 5 <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5 <br /> Industrial Cable Tool Dia. of Well Excavation 2411 <br /> Domestic/private Drilled Dia. of Well Casing 161' <br /> T Domestic/public Driven Gauge of Casing A <br /> 1i-T- Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information <br /> i t <br /> INSTALLATION.- Contractor <br /> SMP Type of Pump H.P. <br /> 4 PUMP REPLACEMENT: / / State Work DoneT-r <br /> 11MF REPAIR: /-7 State Work Done <br /> YIRSTRUCTION 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 /> id the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter 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 /> Pformation is true to the best of my knowledge and belief. <br /> SIGNED / ; A TITLE <br /> (,nW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �7 -- <br /> rPLICATION ACCEPTED BY DATE <br /> DITIONA.L COMMENTS: <br /> PHASE II GROUT INSPECTION \ P E, INSPECT <br /> INSPECTION BY DATE <br /> INSPECT By E <br /> `1 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />