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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F=OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,2 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Fpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'Id/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 /> F)B ADDRESS/LOCATION BRENNEN RD - 14 16ET.I. CENSUS TRACT <br /> aner's Name PHILLIP CHINCHILO & SONS Phone ' 982 .0344 <br /> r <br /> `dress 20848 E. RIVER RD. City RIPON, CAL.- <br /> nntractor's Name HENNINGS BROS. DRILLING CO. , INC. License #116322 Phone 522-5643 <br /> j <br /> F <br /> PE OF WORK {Check) : NEW WELL /�/ DEEPEN / / RECONDITION / / DESTRUCTION /J]`PUMP INSTALLATIONX PUMP REPAIR / / PUMP REPLACEMENT /_7Other / / <br /> .[STANCE 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 /> U Industrial Cable Tool Dia. of Well Excavation 24r' s <br /> Domestic/private Drilled Dia. of Well Casing uhf# <br /> Domestic/public Driven Gauge of Casing r�r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> I; Other Other Information_ <br /> gLW INSTALLATION. Contractor <br /> F $ Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ) �_ Z-- �! <br /> rMP REPAIR: / / State Work Done <br /> LSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .. <br /> ti <br /> d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS - <br /> __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 /> l"lformation is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> RAW LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> rPLICATION ACCEPTED BY DATE <br /> mITIpNAL COMMENTS: <br /> PHASE II GROUT INSPECTION I / AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BV,, DATE <br /> FCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />