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SAN JOAQUIN LOCAL .RLALT11 DISTRICT 1 <br /> FOR OFFICE USE: 1-601 1s'. Hazelton Ave. ,' Stocicto., Calif. i <br /> Telephone: . (20{9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM. DATE -ISSUED : Date Issued <br /> (Comp let6 1n Triplicate) <br /> w Application is hereby made to'' the San Joaquin Local• Health District for a permit to construct <br /> and/or install the�V6rk7herein 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. ;: <br /> JOB ADDRESS/LOCATION 2OG�9 �. �7`G✓ 2 CENSUS TRACT " <br /> Owner's Name ANDY ALFIERI Phone 838-2396 <br /> Address 1. 206.791E . HIWAY 120 ESCALON CALIF. City <br /> HENNINGS �BROS. DRILLING CO. INC. License #116322 Phone 522-5643 <br /> I Contractor's Name } 1 <br /> TYPE OF WORK (Check} : NW WELL /X/ DEEPEN / / REGONDITIQN /� DESTRUCTION'/? 4` ' <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PCSMP�REPLACEMENT /? ` <br /> Other i/% [ ! <br /> 4 i f <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES kI '-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> g INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrials 1 Cable Tool Dia. of Well Excavation <br /> Dome'st'ic/private Drilled Dia. of Well Casing 141t j <br /> k Domestic/public Driven Gauge of Casing ' <br /> X Irrigation I Gravel Pack Depth of Grout Seal - u, <br /> Other _ Rotary • Type of Grout <br /> Other Other Information <br /> + I r <br /> ' PUMP' INSTALLATION: Contractor + ^ flv <br /> Type of Pump - 4 •�, �,� : . H.P. <br /> PUMP REPLACEMENT: / '/ State Work Done <br /> ;PUMP REPAIR: / +/ State Work Done <br /> ,DESTRUCTION OF.WELL: We`ll 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 u`se. The above <br /> information is true to the best of my knowledge and belief. <br /> 1 <br /> �. SIGNED ' A A AA, A A TITLE "' CONTRACTOR <br /> '03 PLAN ON REVERSE SIDE <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> __ " --DATE � 5� 72 <br /> APPLICATION ACCEPTED BY - - ---•- - - -� TM .� , -.�-� --. --._._._ � __ ,_ T <br /> ADDITIONAL COMMENTS: a <br /> y . PHASE TI GROUT INSPECTION PHAS Ii FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION -BY DATE (� <br /> CALL'FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL- INSPECTION. <br /> p E,H 1426 4/72. 1M `' <br />