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_ , SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAjOFF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ 2, Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,4_�ZY- f" <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 Joaquint-Local Health District. <br /> JOB ADDRESS/LOCATIONV3 040 So. Jacktone Rd. lst.,place on East.. Sid eENSUS TRACT <br /> South of Hwy <br /> Owner's Name Bill 'Kamps Phone 599-3089 <br /> Address 23040 South Jacktone Rd. _ . <br /> City Ripon, Cal. <br /> Contractor's Name Hennings Bros. Drilling Co. � Inc. License 90813 Phone 522-1031 -n� <br /> W. Rumble Rd. Modes oa . 95350 <br /> TYPE-OF WORK-- (Check) : . NEW=WELL `/X DEEPEN-/77- 'RECONDITION.` /7 ' DESTRUCTION Y� <br /> AL /7—pump <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT f <br /> Other / / �A <br /> 0 <br /> �ISTANCE TO NEAREST: SEPTICITANK� SEWER LINES = PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ZdV_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL " CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 1" <br /> X Domestic/private + Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection i X Rotary Type of Grout' Bentonite <br /> Disposal ' k Other Other Information Slab y owner <br /> Geophysical. Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> Y <br /> j PUMP REPLACEMENT: / / State Work Done <br /> j PUMP '.REPAIR:. /7 State Work Done <br /> M&TRUCTION 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 /> 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 /> 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 CALL .FOR'A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED ` TITLE <br /> '(DRAW PLOT PLAN ON REVERSE SIDE) L c �Fu <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -Z 3 <br /> ADDITIONAL COMMENTS: <br /> 1PHAS II GROUT INSPECTION r _ PHASE I FINAL INSPECTION <br /> INSPECTION BY Ji-- DATE INSPECTION- BY DATE : S <br /> tlE H._142-6 Rev. 1-74 - 1-74 2m--.- <br /> Y.. <br />