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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO9OFF CE USE: 1601 E. Hazelton Aves,, Stockton, Calif. <br /> y 1 Telephone : (209) 466-6781 <br /> , r APP ICArION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,2- 4J <br /> THIS PERMIT--EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaqui.n'Locai Health District. <br /> JOB ADDRESS/LOCATION AW� vex" /0-?�tagne iRd.--1mi] eSmith of Hwy 120�_. CENSUS TRACT <br /> Owner's Name ""s Ken Hoogendorn west side Phone <br /> 599-3667 <br /> Address 191-29 S. Wagner Rd. City Ripon <br /> Contractor's Name Henning-s- License # Phone <br /> 00 W. 'R=hj@==U 522-1031Mod <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / DUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other !/ / -- <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY_ <br /> SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT O E <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial # . Cable Tool Dia, of Well Excavation 20" <br /> ' Domestic/private Drilled Dia. of Well Casing 12" <br /> --,--Domestic/pub1ic� �-: -��Driven- �_ � � -- <br /> ..• -Gauge�of Gasi g-=-:i1 6-G-.� 4 l.w <br /> X Irrigation - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I X Rotary Type of Grout ,. <br /> Disposal I Other Other Information' Slab-by owner <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_ / State Work Done.-_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 i <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING-AND A FINALt INSPECTION. <br /> SIGNED HENNINGS BRO 9. DRILLING CO. p INC. BY TITLE <br /> DRA �PLIDT PLAN ON REVERSE SIDE) <br /> FQVDEPARTMENT USE ONLY <br /> PHASE I 0, i <br /> APPLICATION ACCEPTED BY DATE 1 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTIONPHAS / N INSPECTI i <br /> INSPECTION BY - DATE INSPECTION BY ' DAT <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 t' .. , <br />