Laserfiche WebLink
M <br /> SJOAQUIN LOCAL HEALTH DISTRICT(— <br /> "� <br /> '0&:OFFICE USE: 1601:.__. Hazelton Ave. , Stockton, Cale.. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�7f!'w <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)- r <br /> plication is hereby made to the San Joaquin Local health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin <br /> ,unty Ordinance No. 1862 and the. Rules and Regulations of the Sa}n�'Joaqu}in Local Health District. <br /> -B ADDRESS/LOCATION 2225 N-Ryon _R_d'.=:J _-North off' MjjgQo_Rd.2.4 CENSUS TRACT , <br /> east . side <br /> net's Name Francis Groen Phone 599-6619 <br /> dress. 22752 N. Ripon Rd. „ City ' Ripon - -- <br /> ntractor's Name Hennings Bros Drilling Co ` Inc. License # 290$1 _Thune X22-1011 <br /> 2500 W. Rumble Rd., Modesto <br /> PE OF WORK (Check): NEW WELL/V DEEPEN '/ / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other L/ <br /> STANCE TO NEAREST: SEPTIC TANK /LV! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation 1111 i <br /> K Domestic/private Drilled Dia. of Well Casing 6-5Z <br /> Domestic/public Driven Gauge of Casing 12 GA ._ <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> _ Cathodic Protection X . Rotary Type of Grout Be_tonite <br /> Disposal Other Other Information Sla b- by owner <br /> Geophysical _Surface Seal Installed B • driller <br /> MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> MP REPLACEMENT / / State Work Done <br /> MP .REPAIR: / / State Work Done <br /> S•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <br /> .d the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .LL DRILLERS REPORT of the well and notify them before putting the -well in-use.. . The above <br /> formation is true to the-best-of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> LOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED. Hennings Bros. Drilling Co. Inc . b 'TITLE See* <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> O EPARTMENT USE ONLY <br /> ASE I <br /> ,PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION A"o' 1 <br /> II •IN INSPECTI <br /> 'SPECTI_ON BY DATE s y" jL INSPECTION DATE <br /> J_ , <br /> 'G�iT'��G i G7`6i4i -YcT C'rr� q� /� lkl� 4w)1411A 1 � <br /> 475 2M <br /> E'S_1426ry Rev. .1-74 r, ,• 5>��3 ri'� <br />