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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone:-- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7? -:7 d <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br />[ Application is hereby made` to the San-Joaquin Local Health District fora permit to' construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and''t the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S.W. CORNER OF WAGNER & MELLO RDS. CENSUS' TRACT <br /> :i <br /> Owner's Name -FRED BURRI JR <br /> . � � Phone X99-4891 <br /> Address 20699 S. WAGNER .RD. City RIPON <br /> Contractor's Name HENNINGS iBROS. DRILLING CO. 5 INC. License # 290813 Phone 522-1031 <br /> 2500 W. <br /> TYPE.OF WORK (Check) : NEW WELL'�/X�/ .DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br />` Other #/ / <br /> DISTANCE TO NEAREST: SEPTIC ITANK �+JS� SEWER LINES PIT PRIVY CJI <br /> SEWAGE .;DISPOSAL FIELD %!5:/- CESSPOOL/SEEPAGE PIT OTHER ,ZQ� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q. <br /> Industrial i Cable Tool. Dia, of Well Excavation 1111 Eft <br />{ <br /> _LX Domestic/private Drilled Dia. of Well Casing it tlantin. <br /> Domestic/public { Driven Gauge of Casing _ <br /> irrigatian — 'ravelyPack Depth-of Grout Seal r QO <br /> Cathodic Protection ^ `TX T <br /> _ � y Type of Grout Bentonite <br /> Disposal Other Other Information Slab--by owner <br /> Geophysical ' F Surface Seal- Installed B driller <br /> PUMP INSTALLATION: ContractoY /� ! <br /> Type of Pump H.P. <br /> _ - .1 <br /> PUMP REPLACEMENT: / / State Work Done <br />—P :REPAIR: -/�/-a..FState=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 <br /> after completion of my work on anew 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 FINALIINSPECTION. <br /> SIGNED BENNINGS BROST, DRILLING. CO. 9 ICN. BY TITLE SEC. <br /> DRAW PT;10T PLAN `ON REVERSE SIDE} <br /> ZFO EPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: J <br /> PHASE I U INSPECTI PHA I/F AL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> '�-E H 1426 Rev. 1-74 4r4r/a! Wei 3/76 2M <br /> .�_ <br />