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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �C,Z-/rolr� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> _?plication 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 /> � <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ; j <br /> ! )B ADDRESS/LOCATION BRENNEN RD . # 5 WELL CENSUS TRACT <br /> rnerts Name PHILLIP CHINCHILO & SONS Phone 9$2-0344 <br /> nddress 208 .8 E. RIVER RD. City RIPON, CAL. <br /> r;ntractor's Name KENNINGS BROS. DRILLING CO. 5 INC, License #11§322 Phone 22- 64 <br /> k <br /> '!-"PE OF WORK (Check): NEW WELL /x% DEEPEN / / RECONDITION /7 DESTRUCTION /7 <br /> f � PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <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 /> a Industrial Cable Tool Dia. of Well Excavation 241? <br /> Domestic/private Drilled Dia. of Well Casing 1611 <br /> C-' Domestic/public Driven Gauge of Casing 1t__._ <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information c� <br /> G <br /> _PUMP INSTALLATION: Contractor <br /> w Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> riVP REPAIR: / / State Work Done ! 7..3 <br /> f PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i � F <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f A 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 /> :formation is true to the best of my knowledge and belief. <br /> a <br /> t SIGNED TITLE <br /> r., RA PLOT PLAN ON REVERSE SIDE <br /> 1. FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> PLICATION ACCEPTED BY ATE - �l <br /> 01TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E II I INSPECTION <br /> INSPECTION BY DATE INSPECT ATE .� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 IM <br />