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kyr }� l/ • • OM1. N - '-:.,�'S , <br /> i SAN JOAQUIN LOCAL REALTH. DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave; , Stockton, Cali <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z ,� 99 <br /> x�r <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 Joaquin Local Health District. <br /> k <br /> JOB ADDRESS/LOCATION 21205 South Wagner 1/2 Mile S. of Mel1ENSUS TRACT <br /> Owner's Name Ted Viss E Phone 599-6691 <br /> Address 21205 So. Wagner City Ripon, Cal. . <br /> I <br /> Contractor's Name Hennings 'BrOS . Drilling Co, , .Inc . License #2-90813 phone 522-1031 <br /> 2500 West? Rumble Rd. Modesto Cal. 95350 <br /> TYPE OF WORK (Check) : NEW WELL/W DEEPEN / / RECONDITION f-1 DESTRUCTION /7 <br /> PUMP INSTALLATION ,-/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other,./-/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 5 OT SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> �- Industrial I Cable Tool Dia. of Well Excavation lln rV <br /> X Domestic/private ! Drilled Dia, of Well Casing 6T, MSTIC \ <br /> Domestic/public I Driven Gauge o€_ Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ? Seal <br /> Cathodic,:Protection I- Rotary- Type of Grout Bentonite U) <br /> Disposal Other Other Information Slab by Owner <br /> Geophysical Surface Seal Installed S Driller' <br /> PUMP INSTALLATION: Contractor r <br /> i Type of Pump H.P. j <br /> PUMP REPLACEMENT: /-7 State Woik-Done ; <br /> PUMP .REPAIR: State Work D ne <br /> DESTRUCTION OF WELL: Well tiameter Approximate Depth s <br /> Describe Material and Proc dure <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 /> a�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 /> information is true to the best of my knowledge and belief. I WILL CATL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ING CO,. , INC . TITLEB KPR <br /> DRAW PL OT PLAN 'ON REVERS E S IDE) <br /> F'0 EP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1� <br /> ADDITIONAL COMMENTS: V <br /> PHASE II GR UT INSPECTION PHASE II/ N NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY �' DATE <br /> E H 1426 Rev. 1-74. 2M <br /> = � ' �" 3/7 6 <br />