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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOFj1?F1 E: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;>,7- 3SO W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1f�7- -7,7 <br /> - <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 Jaaggin' <br /> County Ordinance No. 186�and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � 3 ENTERPRISE RD. ESCALON _ CENSUS TRACT <br /> Owner's Name MERTON BELL Phone 847-5611.'• <br /> Address 11.2.97 ORANGEBLOWOM RD. City OAKDALE, CAL <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 290813 Phone 522-1031 <br /> 2500 WEST RU LE RD. MODESTT-ML . 25350 <br /> 1 <br /> TYPE OF WORK (Check); NEW WELL DEEPEN/7 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / FUMP REPAIR / / PUMP REPLACEMENT / <br /> Other ! / <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP6SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC ELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' � <br /> .Industrial' Cable Tool Dia. of Well Excavation <br /> X Domestic/private '- Drilled Dia. of Well Casing Plastic <br /> `Domestic/public _ Driv`en - - Gauge of Casing _ W. <br /> Irrigation Gravel Pack Depth of Grout Sea] 501 <br /> . <br /> Cathodic Protection XX Rotary Type of Grout Be ntoillzd <br /> Disposal Other Other Information <br /> -Geophysical. Surface Seal. Installed By .driller <br /> PUMP INSTALLATION: Contractor I e-12 . mar <br /> Type of Pump H.P. <br /> R _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP .REPAIR: / % State Work Done <br /> AE„ ES_ iRRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Terial and Procedu e <br /> I hereby agree to comply with all laws and re ' lations of the an Joaquin Local Health istric� . <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 Di..strict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above . <br /> informati.oa is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED: B . TITLFe� f/ Illi <br /> LY(DRAW' PLOT PLAN ON REVERSE SI <br /> FOR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS- <br /> PH <br /> OMMENTS: `~ <br /> P if GPPUT INSPECTWNI PHASE II/,. N - INSPEC I <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 � Rev.. 1-74 //� �° (;Sr 9 a/u/�7�PL _ / � - <br />