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T a �L/ <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> ,FdR OFFICE USE; 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a _/3 <br /> fV <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to 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 Joaqui: <br /> County Ordinance No. 1862 and the -Rules•.and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION BRE NNEN RD. - 2WELL 4onj•_ ��!?-O'to rvl <br /> - c�Nsys . <br /> TRACT <br /> Owner's Name PHILLIP CHINCHILO & SONS <br /> Phone 982-0344 <br /> Address 20$48 E. RIVER RD. <br /> City RLPON, CAL. - <br /> Contractor's Name HENNINGS BROS. DRILLING COT. INC. License # 115 22 <br /> i 3 ghone522--5543 <br /> �-TYPE'OF WORK (Check): NEW WELL /77 DEEPEN /? RECONDITION /_f DESTRUCTION <br /> € PUMP INSTALLATION 1_7 —Pump REPAIR /'7 O <br /> F Other /% // PUMP REPLACEMENT <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSP04L/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool, . Dia. of Well Excavation 2V"— <br /> s` <br /> Domestic/private Drilled Dia. of Well Casing 1 .e: <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing rF _ <br /> Gravel Pack Depth of Grout Seal <br /> Other — <br /> r �X Rotary <br /> Type of Grout • <br /> Other _ Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. _ <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP REPAIR, /% State Work Done <br /> ESTRUCTION OF WELL: Wefi jameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree 'to comply with all laws and regulations of the San 7oaquin Local Health District <br /> and the State -of California pertaining to or regulating well construct <br /> after coaq+letion of my work in FIFTEEN DAYS <br /> on anew ion. Withwell, I will furnish the San Joaquin Local Health District a ' <br /> WELL DRILLERS REPORT of the well, and notify them before <br /> information is true to the best of know putting the well in use. The above 3 <br /> y ledge and belief. <br /> i SIGNED <br /> TITLE <br /> PLOT PLAN ON REVERSESIDE <br /> } <br /> FOR ARTMENT USE ONLY <br /> PHASE I - �. i <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS.- . ATE k <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE IN5PEC gY $ INSPECT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. E <br /> E H 1426 <br /> - 7/72 1M <br />