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IS <br /> --SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> For!,"--,OFFICE USE: 1I 1601 E. Hazelton Ave. �yn.'� <br /> Stockton, Calif. P <br /> Telephone: - (209) 466-6781 ��G Lip <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> :1 <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 stealth District for a permit to construct r <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 o£ the San Joaquin Local Health District.' ; <br /> 4 <br /> JOB ADDRESS/LOCATION Highland Ave off West Ripon Rd. 13201 North CENSUS TRACT.' <br /> �. <br /> Owner's Name John Wes is tyn Phone 599-4980 <br /> Address 13010 E� Wes t Ripon Rd. CityRipon, Cal. <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc.' 290813 52,2-1031 <br /> Lice s # Phone , <br /> 2 00 West 'on ' es .o, a _:• 95.3 <br /> I: <br /> TYPE OF WORK (Check).- NEW WELL /7 DEEPEN 7 RECONDITION I7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR -/ / PUMP REPLACEMENT f7 , <br /> Other <br /> II �- <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 QL1 8EWER LINES QG PIT PRIVY ^1 rr\ <br /> SEWAGE DISPOSAL F1ELD3etZ._ <br /> Ll CESSPOOL./SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial. ' Cable Tool , Dia. of Well Excavation 2611 <br /> Domestic/private '&T Drilled Dia. of Well Casing 14 <br />�.Lome's-t is/pub l.i Driven .�..__ <br /> Irrigation Gravel Pack .,..=De th of Grant Seal <br /> ' , +'a .-�� ' p <br /> " Cathodic.Protection.` Rotary. »,. Type of Grout <br /> Disposal , i ... OtherOther Information e <br /> Ceophystfcal Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done ' <br /> PUMP 'REPAIR:` / / :State Work Done "`"`'A { <br />)ES•TRUCTION -OF WELL: Well-Diameter <br /> Approximate Depth <br /> Desciibe Material and Procedure <br /> L hereby agree to comply with 'a11 laws .and regulations of the San Joaquin Local Health District <br /> Ind theiState of California' Oertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after 'completion of my' on a new well, I will furnish the San Joaquin Local Health District <br /> TELL DRILLERS REPORT of the well and notify them before putting.. the..wel1. in-use.. . The above <br /> Lnf ormae16n.'is true,io the'best'of' my..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION t <br /> IRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 31IGNED •. <br /> (DRAW PLOT PLAN ON REVERS SIDE i <br /> "M DEPARTMENT.USE ONLY <br />'RASE 'I � <br /> LPPLICATION ACCEPTED BY <br /> DATE + <br /> LDDITIONAL COMMENTS: G l <br /> PHASE II GROUT INSPECTIONP III/FjdTAL INSPECTIO f <br /> CNSPECTION BY ll DATE. INSPECTION BY DATE / <br /> E H 1426Rev. 1-74 !� � <br /> _ ._.. ...._._.- __ . .._.. 1,hq 9M <br />