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P SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-I3 3J�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED Date Issued - g <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/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 /> -)B ADDRESS/LOCATION RIVER RD.-2ND MAILBOX EAST OF WAGNER RD. CENSUS TRACT <br /> SOUTH SIDE <br /> Owner's Name ALLEN RANCH CHUCK MIDDLETON Phone <br /> _idress 18700 E. RIVER RD. City RIPON <br /> - )ntractor's Name HENNINGS BROS . DRILLING CO. ,INC . License # 2 081 Phone 522-101 <br /> 2500 W. RUMBLE RD. , MOD. <br /> " SPE OF WORK (Check) : NEW WELL /f/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> [STANCE TO NEAREST: SEPTIC TANK adx SEWER LINES (�r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD nanp. CESSPOOL/SEEPAGE PIT OTHEReC/;b _70Q' <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 241t <br /> Domestic/private Drilled Dia. of Well Casing 161r V <br /> Domestic/public Driven Gauge of Casing 1GA <br /> 4 <br /> Irrigation X Gravel Pack Depth of Grout Seal 4 <br /> C—ah—o-dic Pr�ection -$--Rot- - y� pe of Grout <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical 7 (7 ) Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S d <br /> PUMP REPLACEMENT: / / State Work Done <br /> TMP .REPAIR: / / State Work Done <br /> n1;STRUCTION 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 /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> -iter 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 /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :IOR TO GROUTING AND A FINAL INSPECTION. ,�l <br /> SIGNED N1 S BROS.. . ,INC. Bi' TITLE 7T� p SEC. v" <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,7111,,42 <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />