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q 7 3Y/7 <br /> SAN 30AQUIN LOCAs. HEALTH DISTRICT 3 N 5/e* "/+ 4L►$, <br /> FO$ OFFICE USE: 1601 E. Hazelton Ave.,, Stockton, Calif. <br /> Telephone: -(209) 466-6781 laJq-ora,41e a <br /> APPY:ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> . a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ..ISSUED Date Issued <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 LocalAealth -District. <br /> J16533 ESCALON-BEELOTA HWY--1 MI NORTH OF HWY .120 <br /> JOB ADDRESS/LOCATION _+,MI QFF-ROAD gN WEST _ _� �,, CENSUS TRACT <br /> Owner's Name CARL SERPA Phone <br /> Address <br /> J 16533 E CALON-BELLOTA HWY City <br /> 3 <br /> Contractor's Name HENNINGS BROS. DRILLING 'CO'. INC. License # 2908 <br /> 13 Phone # <br /> 2 00 W. RUMBLE RD. MOD'. 9 <br /> TYPE OF WORK (Check): NEW WELL 'jg DEEPEN '/-7 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7—PUMP REFLACEMENT /7 <br /> Other / 7 <br />-DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES QQ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS POOL/SEEPAGE PIT OTHERO,(d Jl 90 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> � <br />; V_ Industrial __^ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing. <br /> �._� �1 <br /> Domestic/public Driven <br /> -� s Gauge of Casing-- <br /> -- _ ,.. . . <br /> Irrigation.. Gravel. Pack Depth of Grout Seal <br /> ' Cathodic Protection Y Rotary Type of Grout <br /> " Disposal Other Other Information44 ""- <br /> Geophysical` Surface Seal Installed 'By: sia� <br /> AJifl? INSTALLATION: Contractor <br /> �. Type. .of Pump H.P; <br /> PUMP REPLACEMENT: - / / State Work.Done <br /> PUMPPAIR: / / State Work Done <br /> ESTRUCTION OF WELL:. Well. Diameter Approxiidate Depth <br /> Describe Material, and Procedure <br />-1 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"constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District <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. I WILL CALL FOR A 'GROUT INSPECTION <br />?RIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING CO INC : DX TITLE <br /> JDRAW PLOT PLAN ON REVERSE SID <br /> IV <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY ATE <br /> ADDITIONAL COMMNTS: i <br /> P I UT SPECTIO PHA II AL INSPECTI <br /> INSPECTION BY DATE 3 INSPECTION BY DATE <br /> E H 1426 <br /> Rev. 1-74 �� 7 . + <br />