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SAN JOAQUIN LOCAL HEALTH DISTKT <br /> FQE �OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 `9�tr� <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 fora 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 4the-45an Joaquin Local Health District. F <br /> f <br /> JOB ADDRESS/LOCATIONRue R ' CENSUS TRACT j <br /> Owner's Name Henry De Jong Phone <br /> Address 1-3158 West Ri-pon Rd. CityRipon <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License # 2 081 Phone ' 522-1011. <br /> 2500 W. Rumble Rd. Mod, <br /> TYPE OF WORK (Check) : NEW WELL /x/ DEEPEN '/—/ RECONDITION /_% -DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUNA' REPAIR '/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYPk ell <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 0. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS �. <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> 2411 <br /> Domestic/private Drilled Dia. of Well Casing 1 s \ <br /> ' Dame-sti c/public-TDriven--=�- =Gauge <br /> X _ Irrigation I�, X Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection X 'Rotary Type of, Grout. - ; <br /> Disposal Other Other Information Slab-by owner � <br /> Geophysical �� Surface Seal Installed By: 1 _ <br /> I L <br /> PUMP INSTALLATION: Contractor A10 414 wY) v+"l��? <br /> Type of Pump 7 H.P. <br /> PUNA' REPLACEMENT: . /,p 7 State Work Done <br /> PUMP .REPAIR: /mil / State Work Done <br /> ,DESTRUCTION OF WELL: W'-11 Diameter . Approximate Depth j <br /> Describe Material and Procedure <br /> 'thereby agree to complyi1with- 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 <br /> WE LLERS REPORT of "the well and notify them before putting the .well in use. The above <br /> ormat'on is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AND A FINAL INSPECTION. <br /> S GNED up t TITLE t <br /> JM (DRAW..RUN PLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> LS E I <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: J. <br /> PHASE II GROUT INSPECTION PHASI/j.ftNAjLINSPECTI <br /> IPECTION BY ilin, �M DATE INSPECTION BY DATE <br /> } �! <br /> E� H' 1426 . Rev. 1-74 .r 3/76 <br />