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.f <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160f- E. Hazelton Avt. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 3LN vel <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.k-�:3_ 3 <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 CENSUS TRACT " <br /> Owner's Name Rny Koch Phone838..7745 <br /> Address 2Q2$ F:11 -i r, Rd, City Escalon <br /> Contractor's Name Hennings Bros. Drilling Co. }Sncp_-_ License # 116322 Phone 522- 643 <br /> 2500 X, Rumble RdModesto <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK "I SEWER LINES PIT PRIVY --1 <br /> SEWAGE DISPOSAL FIELD V,�2t CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 90 <br /> Industrial Cable Tool Dia. of Well Excavation IV <br /> x Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 GA— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other x Rotary Type of Grout <br /> Other Other Information j_j9jj_ By Owner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> s PUMP REPLACEMENT: / / State Work Done <br /> r <br />-PUMP-REPAIR-.- T / /" =State7WOx Done <br /> _RESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe .Material and Procedure <br /> i <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- a <br /> l 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. <br /> I' <br />, SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F DEP T USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEP BY f DATE i <br /> 31, <br /> ADDITIONAL CO <br /> I UT INSPECTION P FINAL INSPECTION <br /> INSPECT DATE INSPECTION BY j r DATE — `X0 ,�'5 <br /> CALL FOR A GROUT .INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 . 7/72 1M <br />