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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� r <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issued 7� <br /> (Complete In Triplicate) <br /> Application it; fiereby. made :to the San Joaquin Local Health District for a permit to. cons;r4ct <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 ESCALON-BELLOTA HWY.-BEEN MAHON RD'. & CENSUS.BRACT. :: . <br /> Oraner's Name .' REED RANCH •^ <br /> Phone <br /> Address._. , 15885 S . ESCALON-BELLOTA HWY City , ESCALOM <br /> Contractor's Name., HENNINGS BRCS. DRILLING CO. INC. License �E -290813Phone .522-1031 + <br /> • RIU MJ31,E RD. <br /> MUD <br /> TYPE ,.OF.WORK (Check): NEW WELL /17 DEEPEN /-7 RECONDITION /'7 DESTRUCTION /7 } <br /> PUMP INSTALLATION / % PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC' TANK qnool SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAD-FIELD CESSPOOL/SEEPAGE P1T OTHER' <br /> PROPERTY LINL. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPRCIFICATION$ <br /> IndustrialCable Tool Dia. of Well Excavation ��er <br /> Domestic/private Drilled Dia. of Well Casing 1 Rit <br /> Domestic/public Driven Gauge of Casing <br /> r- Irrigation - X Gravel Pack Depth of Grout Seal �l <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information 2 SLAB-By„ R <br /> - Geophysical .�.�--,.,.... <br /> Surface Seal Installed B : <br /> PUMP INSTAL TION: <br /> Contractor . <br /> Type of Pump H* . . . . <br /> P1W REPLACEMENT: / ./ State Work Done <br /> PUMP .REPAIR: /7. State Work Done fyf <br /> i <br /> AS-TRUCTION OF WELL: Well_Diameter Approximate .Depth' ' f <br /> -Well-Di <br /> Material and' Procedure <br /> 1-hereby agree to comply with all laws and. regulations of the' San Joaquin Local Health 516trfct f <br /> and ,the State of California pertaining. to or regulating well ''construction. Within .]FIFTEEN RATS # <br /> after completion of my work on a new well„ I will furnish the San Joaquin Local Health.Dist;ict <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in use... The above. <br /> information 1s 'true to the best. of- my knowledge and belief, I WILL CALL FOR A CLOUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ° <br /> SIGNED' HENNINGS BBIBS5 D' LL INC`. BY TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> i FOR DEPARTMENT USE ONLY1. <br /> PRASE I , <br /> APPLICATION ACCEPTED BYZZ ; � DATE <br /> ADDITIONAL COMMENTS: <br /> 3 �' ` PHASE 7I GROUT INSPECTION PHASE III/FINAL INSPECTI N. <br /> INSPECTION .SY. DATE INSPECTION BY <br /> E H.1426 Rev. 1-74 yi2 , v� 1/77 <br /> _ 2M <br />