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_ _ � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r'OE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?-1330 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ..,)plication 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 /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION RIVER RD.-2ND MAILBOX EAST OF WAGNER RD.- CENSUS TRACT <br /> SOUTH SIDE <br /> aner's Name ALLEN RANCH CHUCK MIDDLETON Phone <br /> Address 18700 E. RIVER RD . City RIPON <br /> .ontractor's Name HENNINGS BROS. DRILLING CO. 3INC. License # 2 081 Phone 522-10 1 <br /> 2500 W. RUMBLE RD. , MOD. <br /> SPE OF WORK (Check) : NEW WELL /X/ DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK apXe SEWER LINES /26r)le PIT PRIVY <br /> SEWAGE DISPOSAL FIELD fJ0')iP. CESSPOOL/SEEPAGE PIT 0THE Fetfhb -70,0 <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 �l�n <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ('rA <br /> Irrigation X Gravel Pack Depth of Grout Seal _ 4 <br /> Cathodic Protection X Rotary Type of Grout •- V 1-1 <br /> rf <br /> _ Disposal Other Other Information SLABBYOWNER <br /> Geophysical -7j07) Surface Seal Installed By: .» <br /> UMP INSTALLATION: Contractor U 5 _ <br /> Type of Pump a H.P. <br /> UMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> ES-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 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> r&nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> B�' TITLE BIZ, SEC. o" <br /> SIGNED S R • <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> -1HASE I <br /> _OPLICATION ACCEPTED BY6e <br /> DATE % <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II FI INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br />