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SAN JOAQUIN ;LOt tL HEALTH DISTRICT 0&a <br /> :. _ <br /> FOF <br /> 6F_FI E 'U <br /> CSE: 1601 E. Hazelton Ave. , Stockton, Calif,, <br /> Telephone: , (209) 466-6781 . .® r <br /> _ APPLICATION FOR WELL,XONSTRUCTION OR PUMP PERMIT Permit No A0 � . <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 pr-� ' �+Y�aet <br /> and/or install the work herein described. This application is made in come r__ _F _ Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ayers, Ave. between. Carrolton & Van Allen CENSUS TRACT <br /> Owner's Name Ron Ballance Phone $3$-2103 <br /> Address ..19947 Ayers Ave - City Escalon, Cal <br /> 522-1031 <br /> Contractor's Name Hennings Bros Drilling Co. s .Inc:" License ��290$13 Phone <br /> 2500 Vest Rumble Rd. ModestOL, Cal. 95350 <br /> TYPE OF WORK (Check) : NEW WELL ,X / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other . ... <br /> DISTANCE TO NEAREST: SEPTIC TANK Z& ,. - 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 t,r <br /> X Domestic/private Drilled ¢. Dia. of Well Casing 6� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slhb by owner - <br /> Geophysical -Surface Seal Installed BY: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . 1 . H.P. <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 <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION-- <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. D.�RLLING CO. INC, TITL <br /> DRAW PLOT PLAN ON REVERSE SI E) I: ! <br /> R DEPARTMENT. USE ONLY <br /> PHASE I 011 <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO4 PHASE III4fINAL INSPECT , N <br /> INSPECTIO _Y DATE 1NSPECTION BY <br /> .3 76 2M <br /> E H 1426 Rev. 1-74 <br />