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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FOR OFFECE USE: 1601 E. Hazelton Ave., Stockton, Calif_ <br /> Telephone: (209) 466-6781, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT WIRES" 1 YEAR FROM DATE ISSUED Date'Issued.� <br /> (Complete In Triplicate) <br /> Application is- herebywade <br /> y t• the San Joaquin Local Health District for a permit to construct <br /> _and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance. No. 1862 and the, Rules and Regulations oftheSan Joaquin Local, Health District. <br /> O Lto_ v/ <br /> JOB ADDRESS/LOCATION 13REMN RD- #1 �r,*ELI, _ CENSUS TRACT s <br /> Owner's Name PHILLIP CHINCHILO & ,SONS <br /> Phone 982-034 <br /> Address 20848 E. RIVER RD. RIPON, CALIFORNIA RIPON <br /> City <br /> r <br /> E Contractor's Name HENNINGS $ROS. DRILLING CO*, INC. License #1 1322 Phone 522-5643 <br /> TYPE OF' WORK (Check):. 'NEW`WELL /&_7 DEEPEN F "RECONDITION /_7 "DESTRUCTION /_7 " <br /> PUMP -INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /_ f <br /> Other f_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ^ 'j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �r <br /> Industrial Cable Tool Dia. of Well Excavation re <br /> �— Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing n <br /> X Irrigation Gravel Pack Depth of Grout Seal f <br /> Other _ _ X Rotary Type of Grout <br /> 'Other Other Information <br /> 4 <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump <br /> H. <br /> PUMP REPLACEMENT: <br /> 1`I State Work Done <br /> PUMP REPAIR: -` S <br /> tate Work Done <br /> ESTRUCTION OF WELL: 'Well-Diameter ' - <br /> Describe Material and Procedure Approximate bepth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State'of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after 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 /> information is true to the best of my knowledge and belief. t <br /> SIGNED <br /> +TITLE <br /> T PLAN 4N REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II INSPECTION <br /> INSPECTION BY* DATE INSPE N BY TE <br /> CALL 1`ORtA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />