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R SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> F <br /> OVOFFICE : 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � �E, <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 22 .W. RIPON RD.-^00' WE T OF BAKER :AVE . . CENSUS TRACT <br /> k Owner's Name WILLIAM DE JONG <br /> SOUTH -SIDE - ' <br /> Phone 599-7532 <br /> Address .13822 W. RIPON RD. City <br /> Contractor's Name KENNINGS BROS. DRILLING CO. INC. License # 2__9081 Phone 545.-11'85 <br /> 3�25 PELANDALE AV_E . 1 MOD CA . 0 <br /> TYPE OF'WORK� (Check) : NEW WE:L.L /U/ DEEPEN' / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 125t SEWER LINES PIT PRIVY- <br /> SEWAGE DISPOSAL FIELD 801 CESSPOOL/SEEPAGE PIT OTHER WELL-100 <br /> PROPERTY LINE -_KaLyATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable Tool Dia, of Well Excavation Domestic 1 1 <br /> 'X sr <br /> /private Drilled Dia. of Well Casing _ " PLASTIC <br /> Domestic/public Driven Gauge of Casing160 WALL t- 1 <br /> Irrigation X Graved Pack Depth of Grout Seal 01 <br /> Cathodic Protection X Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: . _ ./.._f State Work Done _ c �1 <br /> fi- e- �= f�fa 1.!rf� M C. <br /> DES-tRUCTION OF WELL: Well Diameter O��J g" <br /> Approximate Depth Z Ci_ <br /> l <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 INSPECTIO <br /> PRIOR TO GROYJTING AND F AL INS E CTION. <br /> SIGNED <br /> TITLE ; <br /> (DRAW PLOT PL ON REVERSE SIDE) <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEf--7 7r <br /> ADDITIONAL COMMENTS: <br /> P S GROUW INSPECTI. N PHASE I / INAL INSPECTIO <br /> INSPECT10N BY DATE t INSPECTION BY DATE--D g <br /> E/071-4 2 <br /> 6 2ev. � 1-74 2M t <br />