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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: *.. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (2093466-081 <br /> �A APPLICATION-FOlt WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 16453 E. MILGEO RD. RIPON / <br /> CENSUS TRACT � lo <br /> Owner's Name R. H. FRANCIS Phone 599-7589 <br /> Address 0. <br /> City RIPON, CAL <br /> Contractor's Name HENNINGS BROS . DRILLING CO. , INC. License # 290813 Phone 522-1031 <br /> 2500 WEST RUMBLE RD. MODESTO CAL. <br /> i <br />_TYPE OF WORK-(Check), -NEW WELL A7, DEEPEN r/_J RECONDITIOh��/ /- �ESTRUCTION�/ <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> 'TANCE TO NEAREST: SEPTIC TANK i SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ��/ OTHER <br /> 4 PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> $-INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> j Domestic/private <br /> Drilled Dia, of Well Casing <br /> Domestic/public Driven _ Gauge of Casing,,,.. <br /> _. . ..� _ _ . �- g g,, _�,. <br /> _ <br /> Irrigation Gravel Pack Depth of Grout Seal 1� <br /> Cathodic Protection Rotary Type of Grout <br /> "�_Disposal Other Other Information <br /> F Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Wefl-biameter Approximate Depth T <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 4 <br /> information is true to the best of- my-knowledge and belief. I WILL C FOR A ;GROUT INSPECTION <br />'RIOR TO GROUTING AND AFINAL INSPECTION. Inc. TITLE � gpR <br /> DRAW-PL T PLAN ON RE ERSE SIDE) <br />?RASE I R DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: ` <br /> PHASE IIG40UT INSPECTION PHAS IIIhFINAL_-INSPECTION <br />[NSPECTION BY <br /> DATE INSPECTION BY DATE <br /> AV <br /> E H 1426 Rev. 1-74 ` � ✓/�'�,�-- r►.b ^,.,Va 3/76 2M <br />