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�LQ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, Z?-,1z0kJ <br />'i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-�02-7� <br /> (Complete' In Triplicate) <br /> application 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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District; <br /> FDB ADDRESS/LOCATION BRENTTEN RD. s. <br /> - � 3 WELL CENSUS TRACT <br /> rnerls Name PHILLIP CHINCHILO & SONS Phone 982-0344 <br /> 2 - - - <br />�k <br /> address 0848 E. RIVER RD. City RIPON, CAL. <br /> F:Intractor's Name HEN19TNGS BROS . DRILLING C09 , INC. License # 116322 Phone 522--5643 <br /> SPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> FIESTANCE <br /> 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 24ri 75 <br /> Domestic/private Drilled Dia. of Well Casing _ 16" <br /> - Domestic/public Driven Gauge of Casing <br /> LX Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information <br /> W <br /> }XJMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> F—mPREPAIR: / J State Work Done J L-1(- 77 <br /> 1W.STRUCTION 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 /> M 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 /> iformation is true to the best of my dcnowledge and belief. <br /> 51� <br /> �_ �SIGNED � TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I 17— <br /> PMELICATION ACCEPTED BY ATE �� <br /> PLICATION <br /> COMNTS: f <br /> PHASE II GROUT INSPECTION �� P I, �A�INSPECT NINSPECTION BY DATE INSPECT ON B TE <br /> 1 ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />