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SAN JOAQI ', L=t HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton ire. , Stockton, Calif. <br /> . ,. <br /> Telephone: (209) 466-6781 <br /> al APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / -3-01 Ccs <br /> ,rev jo�eLLE v ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,3-,>l 22 <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 Local Health District. j <br /> JOB ADDRESS/LOCATIOIr E. AYERS RD.*»BETWEEN VAN ALLEN & CARROLTON CENSUS TRACT <br /> Owner's Name* ROBERT BALLANCE Phone 838-7777 <br /> Address 20093 E. AVERS RD. City ESCALON <br /> Contractor's Name KENNINGS BROS. DRILLING CO. INC. License # 290813 Phone 522-1031 <br /> 2500 W. RUMBLE RD. , MOD. <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION & PUMP REPAIR'/ / PUMP REPLACEMENT /7 <br /> Other <br /> �QISTANCE TO "NEAREST: SEPTIC TANK IM/ SEWER LINES PIT PRIVY r <br /> `� SEWAGE DISPOSAL FIELD 4 CESSPOOL/SEEPAGE PIT OTHER } <br /> J� PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL " <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11 ' I. X _ Domestic/private Drilled Dia. of Well Casing 6" <br /> Domestic/public Driven Gauge of Casing 160 Walli <br /> Irrigation Gravel Pack Depth of Grout Seal 50, <br /> r Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab-by owner - } <br /> _Geophysical Surface Seal Installed By: driller <br /> PUMPINSTALLATION: Contractor C94 /✓,4� <br /> ' ..z Type of Pump H.P. <br /> TUMP REPLACEMENT: / / State Work Done f <br /> r t, <br /> PU'�iP .REPAIR: y/ ./..: $tate�,W,ork_Done <br /> !STRUCTION OF WELL: Well Diameter - Approximate Depth <br /> PP P <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"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District ar <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 /> PkIO'R TO GROUTING AND A F INS CT1 N. <br /> _SIGN DITLE <br /> (DRAW 2-LOT. T' LAN ON RE RSE SIVE) <br /> FOR PART <br /> MENT USE ONLY 4 <br /> PHASE I t <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> " . PHASE II GROUT INSPECTION PHASE /FIN INSPECTIO <br /> ,r <br /> INSPECTION BY DATE 9 :._. INSPECTION BY ATE <br /> E H 1426 Rev. 1-74t <br />