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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1C.- '` <br /> •O1�FICE US1601 E. Hazelton Ave. , •5tockton, Calif. <br /> Telephone: (209) 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lssued 'r—A ?� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San .Joaquin Local, Health District for a. permit to constr'yet <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 ])Itrice: <br /> JOB ADDRESS/LOCATION ESCALON-BELLOTA HWY-JUST NORTH OF MAGNOLIA CENSUS TRACT. <br /> . :AVE* , WEST SIDE <br /> y. <br /> Owner's NameBEEP RANCH Phgne <br /> Address - 15885 S. ESCALON-BELLOTA HWY -City - ESCALON <br /> Contractor's Name . HENNINGS BRBS'. DRILLING ,CINC'. License # 290813phane - '522--1031: <br /> 2 00W. RUMBLE RD. MOD". ; — <br /> i <br /> TYPE OF WORK, (Check): NEW WELL 47 DEEPEN '17 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT, / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC' TANK r /* .SEWER LINES PIT PRIVY 106 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITRLt1ECL/p(�- <br /> PROPERTY LINE -.:PRIVATE DOMESTIC WELL PUBLIC DOMESTI W L <br /> INTENDEp USE TYPE OF WELL. CONSTRUCTION. S'PECIFICATIONS`' <br /> :Industrial DAIRY Cable Tool Dia. of Well Excavation fA. ' <br /> X_ Domestic/private , -3 Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of CasingQ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ x Rotary Type of Grout <br /> �4 <br /> Disposal - - Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> r , <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump < H ; <br /> t <br /> ItMP REPLACEMENT: / / State Work Done <br /> PUMP .REP I <br /> / / State WorkI)one <br /> _W DES•'TR , TI WELL: Wellriameter <br /> Approximate Depth <br /> e d r be Material an` Proce ure <br /> a. comlyth 1,,hereby agree tegula Joaquin Loc Health ,District <br /> acid the State of Californiapertaining to or regulating well••construction. Within FIFTEEN DAXS. ; <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Hoalth.District. <br /> WELL DRILLERS REPORT of the Well and notify them before putting. the .well in use.. The above. <br /> information 1,s true to the best of: my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ILLING CO. 3 INC. BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> ' OR <br /> QR DEPARTMENT USE ONLY <br /> PRASE T <br /> APPLICATION. ACCEPTED BY DATE . .. Sri <br /> ADDITIONAL COMMENTS: T <br /> P E I ROU INSPECTIQ9 PHASE III FINAL INSPECTION i <br /> INSPECTION 0, DATE INSPECTION BY DATE' 77 1 <br /> rr <br /> E HL1426 Rev. 1-74 x!.77` 2H <br />