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` SJOAQUIN LOCAL HEALTH DISTRICT <br /> OE OFFE USE: 1601 Hazelton Ave: , Stockton, Cali <br /> - "<Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE o. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE OFteVsued <br /> (Complete In Triplicate) <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 Joaq and Regulations of the San Joaquin <br /> unty Ordinance No. 1862 and the Rules Local Health DisAn <br /> triclt. <br /> r <br /> B ADDRESS/LOCATION 21205 South Wagner 1/2 Mile S. of MellCbENSUS TRACT 3 <br /> 4 <br /> Phone 599-w6691 <br /> -ner's Name <br /> Ted Viss g. <br /> 21205 So, 19agner City Ripon, Cal. <br /> dress - 0 1 ! <br /> )ntractor's Name <br /> Hennings Bros . Drilling Co. , Inc, License 6290813 Phone 52'2 1 3 E <br /> 2500 West Rumble L. 95350 , <br /> 'PE OF WORK (Check) : NEW WELL/_V DEEPEN / / RECONDITION / / DESTRUCTION f? <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT — <br /> Other <br /> LSTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL LIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS S <br /> INTENDED USE TYPE OF WELL 11 TT <br /> Industrial. Cable Tool Dia, of Well Excavation TT a s t! � <br /> X Domestic/private Drilled Dia. of Well Casing y, <br /> Domestic/public Driven Gauge of Casing j { <br /> Irrigation Gravel Pack Depth of Grout Seal 50T Seal <br /> Cathodic Protection . X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab b owner J <br /> Geophysical Surface Seal Insta <br /> Iled B Driller 'I <br /> OMP INSTALLATION: Contractor <br /> M H.P. <br /> Type of Pump r <br /> i <br /> TJMP REPLACEMENT: / / State Work Done <br /> UMP .REPAIR: / / State Work Done <br /> ES•TRUCTION OF WELL: Well �iameter and Approximate Depth <br /> Describe Material Proc dure � <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> :nd 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 /> JELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> k _nformation is true to the best of my knowledge and belief. I WILL C L FOR A GROUT INSPECTIiON <br /> -'RIOR TO GROUTING AND A FINAL INSPECTION. KPR <br /> SIGNED HENNJAGSs. I IMING CO. , INC . TITLEB <br /> (DRAW PLOT PLAN 'ON RE ERSE SIDE) G <br /> FO EP MENT USE ONLY <br /> ?RASE I .� <br /> ,kPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTIO PHASE III NSPECTIO <br /> /. IN <br /> INSPECTION BY t ! DATE ' <br /> INSPECTION BY DATE <br /> - a <br /> E H 1426 Rev. 1-74 OF <br /> -- . �.•;;�if.._..�1�'��7� ._,_. : .� .,., � .� <br />