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Om <br /> r. --- — <br /> _ SAN JOAQUIN LOCAL, HEALTH DISTRICT � +'�'� .q�k. SNS +�-C71o�u <br /> FOR.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. tiJ1 ' <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 6 d'7-J7 <br /> F (Complete In Triplicate) ' <br /> Application is' Aereby made tq' 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 ,N6'.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 29-W+ E. ORANGE AVE.-400' EAST OF SEIDNER RI3CENSUS TRACT j <br /> y.- 1 SOUTH SIDE <br /> Owner's Name JENNIE SIMMONS Phone 838,7564 <br /> Address -29331+ EJ ORANG..E AVE. City ESCALON <br />'I Contractor's Name HENNINGS� BROS. DRILL D G :CO. INC: License �� ;'29081 h ne' �!�.:� 18 <br /> 2 PELAXDALE AVE. MODESTp'� P <br /> TYPE OF WORK (Check) : NEW WELL/X' DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /_7 = �, <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / /� <br /> 3 <br /> i' <br />< <DISTANCE TO NEAREST: , SEPTIC TANK5S` 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 R `' <br /> Industrial .� Cable Tool Dia, of Well Excavation 1111.. ! <br /> X Domestic/private € Drilled Dia. of Well Casing 611 iplastic <br /> Domestic[Pub l c,,. Driven....-s _Gauge. of..Casing 1.6.0 1. �-t <br /> _ Irrigation € Gravel, Pack Depth of Grout Seal <br /> Cathodic Protection _�X Rotary Type of Grout Bentonite <br /> E Disposal. Other Other Information lab-.by„ owner,� <br /> E <br /> Geophysica3 <br /> Sur ace Seal Installed By: driller � <br /> P�fMP. INSTALLATION: Coqitractort#, <br /> . • Type of~Pump H P. . <br /> f PU4 REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR; / State Work Done I pn r 3/-7 <br /> ev <br /> DESTRUCTION OF WELL:: .. W 1 •Dia ter "., ` )CIS Approximate Depth <br /> ' <br /> Describe Material and Procedure <br /> Ilheey agreext'o"" comply w th all laws a reg;ulat ons t e San oaqu n Loca Hea Eh District <br /> i aid-the-LStat of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, T will '-furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 and notify theniibefore 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 GROU ING ANDA FIN NSPECTION. <br /> SIGNED 4TITLE <br /> a (DRAW T PLAN ON RE E SIDE) <br /> j4.F •DEPARTMENT., . ONLY <br />'PHASE I <br /> APPLICATION ACCEPTED BY t -- '` ash ` !�' DATE <br /> ADDITIONAL COMMENTS: <br /> { PHASE II GROUT INSPECTION ' 'E PHASE ITI/FINAL I/FINALINSPECTIONI <br />' INSPECTION BY DATE ' { INSPECTION BY DA E 1117- <br /> -..7,T .k i �d� <br /> E H 1426 ~Rev. -74 1 <br />