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CIA SAN JOAQUII LOCAL HEALTH DISTRICT <br /> FOP--'OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATIONFOR.FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .712- e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'a 3�—AW (Complete In Triplicate) k <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct `z <br /> and/or install the work herein described. 'This application is made in compliance with 'San Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. fE <br /> JOB ADDRESS/LOCATION 17601 S. CAMPBELL RD.-NORTH OF HWY 120- CENSUS TRACT <br /> _. WEST SIDE <br /> Owner's Name AGRO INCORP. Phone 838-7624 <br /> Address 17202 STEINEGUL RD. City ESCALON <br /> Contractor's Name HENNINGS BROS. DRILLING C.O. INC . License # 290813 Phone 545-1185 <br /> 3525 AVE-01 MODESTU <br /> J , <br /> TYPE OF WORK (Check) z NEW WELLX/ DEEPEN; / /•. :RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP .REPAIR ,/ j PUMP REPLACEMENT j� --- <br /> Other �j <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER' LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FI-ELD ,Q r 'CESSPOOL/SEEPAGE PIT OTHER WC-ZL- <br /> s <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation rr - <br /> Domestic/private Drilled Dia, of Well Casing 6s.s. PLASTY <br /> Domestic/public Driven Gauge .of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal. 50t <br /> Cathodic Protection-'' x Rotary Type of Grout BENTONITE- <br /> Disposal Other Other Information LAB—BjQ <br /> Geophysical Surface Seal Installed By: DRILLER <br /> * l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> s <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: a / / 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 /> 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 thewell in use. . The above <br />` information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IPRIOR TO GROUTING ANDA FINAL INSPECTIO . <br /> SIGNED HENNINGS BROS. BY 2 TITLE SEC. <br /> (D W PLOT PLAN ON RE RSE SIDE) <br /> FOR DEP TMENT USE ONLY _ <br /> PHASE I t `_ a3 7e <br /> APPLICATION ACCEPTED BY ;� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE' S GROU T IN PHASE INAL ASPECTI0N <br /> INSPECTION BY ///N ATE / Q INSPECTION BY �ATE <br /> 77 M <br /> R U 1 AI A Dem, 1_7A <br /> 0/ <br />