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V SAN JOAQUIN LOCAL HEALTH DISTRICT �QQ <br /> FOR OFFICE USE: E. Hazelton Ave. , Stockton, Calif. 7 /6/18 '71_ <br /> Telephone: (209) 466-6781 �g <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q___•-_ <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 Ordinange No. the Rules and Regulations of the San Joaquin Local Health District. <br /> /7/ ur d.-Esc4on--Down McHenry past Escalon <br /> JOBS. ON turn 1 ft on Arthur-on 1 ft hand side of rd. by CENSUS TRACT <br /> corn field.� � <br /> Owner's Name Joe Byl G, ma._ Phone 7 LZ <br /> Address 4118 N. Teener Rd., Tnrinnk City Turlonk <br /> Contractor's Name 8tanislaus Pump & Machinp3zy r:nrj�- License //A290355 Phone �331027 <br /> TYPE OF WORK (Check): NEW WELL/—/ DEEPEN / / RECONDITION /-7 DESTRUCTION /7 N <br /> PUMP INSTALLATION /X / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /-7 -� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor St n; l .us Pum M n , e <br /> Type of Pump Meyers h'n r3z-. <br /> Cc�r�xaake <br /> H.P. 1 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 <br /> 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 knowle4ge and belief. I WILk CALL FOR A GROJJT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL NSPE ."e1 <br /> SIGNED Ready -20-78 1 J==KTME <br /> E _��cyi <br /> W. PtOT PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C 9kiw^A DATE /©-n?3-78 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IHJFINAIAINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE z 2f <br /> E H 1426 Rev. 1-74 <br /> 3/764 <br />