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A. <br /> ' SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: ,� 1.601 E. Hazelton Ale.,'-Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -5-,7,3 Z,,,' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 S.W. Corner of W.Ri on R CENSUS TRACT i <br /> Ip <br /> Owner's Name T Henry DeJong _ _ Phone _x599-L.89 4 <br /> Address 1.3150 W. Ripon Rd. City Ri n <br /> Contractor's Name Hennings B x License # 9 WPhone 522 1%, <br /> 2500 W. Rumble Rd. , Mod <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other J-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK 1�2�� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> i INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS X. - <br /> n <br /> Industrial ! Cable Tool Dia, of Well Excavation �7 <br /> Domestic/private Drilled t -, Dia, of Well Casing ' plastic _ <br /> Domestic/public E Driven Gauge of Casing 160 <br />! Irrigation i Gravel Pack Depth of Grout Seal 50t <br /> }� Cathodic Protection ~j X Rotary Type of Grout Bentonite <br /> Disposal 4 ,�� "Other Other Information Slab-by Owner <br /> Geophysical. II' - Surface Seal Installed By: dril e <br /> .49 <br /> PUMP INSTALLATION: Contractor � v <br /> E Type of Pump H.P. <br /> i PUMP REPLACEMENT': % / State Wbrk Done <br /> PUNF—REPAIR: % / State Work Done <br /> DESTRUCTION 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 /> I and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my ;7ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of1the 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;jFINAL INSPECTION. <br /> SIGNED HENNINGS BROS'! DRILLING CO. INC-. By TITLE S,; <br /> I <br /> !"(DRAW PL ' PLAN 'ON REVERSE SIDE) <br /> j� R DEPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P SE 14 GROUT INSPECTION PHASE,-;II/FI INSPECTIO <br />,k INSPECTION BY DATE .� ,2O�7b INSPECTION BY DATE <br /> t 1 p 3/76 2M <br /> E H 1426 --*-Rev. 1-74 <br />