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SAN JOAQUIp ,I,O%"L HEALTH DISTRICT �. Ga/ 'Ca ^1` { <br /> FOF OFFICE `USE: 1601 �E Hazelton Aive. , Stockton, Calif �--- �TM <br /> �{ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL :CONSTRUCTION OR PUMP PERMIT' Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE_ISSUED Date Issued ' <br /> (Completeliln 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. Thil 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 /> f <br /> JOB ADDRESS/LOCATION Ayers Ave., between Carrolton & Van Allen CENSUS TRACT <br /> Owner's Name Ron Ballance Phone $3$-2103 <br /> s <br /> Address. J9947 Ayers Ave - city Escalon, Cal <br /> 522-1031 i <br /> Contractor's Name Hennings Bros, Drilling Co. �k Inc:- License #290813 Phone , <br /> odest�;, Cal. 95350 <br /> 2500 West Rumble - Rd. l�I <br /> TYPE OF WORK (Check) : NEW WELL ,X-j DEEPEN/ / RECONDITION j / DESTRUCTION /� <br /> PUMP INSTLATION/ / 'UMP REP <br /> ALAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER' LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIME DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -111t <br /> X Domestic/private Drilled h, Dia. of Well Casing X— <br /> Gau e of Casio f `� <br /> - Irri ation Graved Pack e t ._g_ � <br /> ' � Depth of Grout Seal 50 <br /> Domestic/public c -public Driven <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slhb by owner - <br /> Geophysical 1 Surface Seal Installed By: driller ' <br /> QLPUMPINSTALLATION-- Contractor ° � j <br /> ,. .,� <br /> Type of Pump ._ ,�,/°II , H.P. j <br /> PUMP REPLACEMENT:—.. / / State Work Done j <br /> PUMP .REPAIR: / / State 'Work Done <br /> DESTRUCTION OF WELL: Well Diameter „ Approximate Depth- <br /> Describe Material and V ocedure• : <br /> I hereby agree to comply with all laws and regiulations ,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-1 <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above j <br /> information 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. IP 1 <br /> SIGNED ' HEhNNINGS BROS D LLING CO. ZINC. TITL 4. E <br /> DRAW P7LT' PLAN` ON REVERSE S I . <br /> R D;!EPARTMENT.,USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE IT, GROUT INSPECTIO4 PHASE IIIHINAL INSPECT N <br /> _INSPECTIO Y PDAE INSPECTION BY DATE <br /> E H 1426 'Rev. 1-74 w.,,,,.., 376 <br /> t <br />