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SAN JOAQUINxLOCAU HEALTH DISTRICT <br /> F6E.OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-•i 77 4�J � <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 foir a permit to;construct <br /> and/or install the work herein.described. This application. is made in compliance with San Joaquin <br /> tCounty Ordinance No. '1$62 and the Ruses and. Regulations of the San Joaquin Local Health District. <br /> fi <br /> JOB 'ADDRESS/LOCATION 20450 So. Van Allen - Escalon CENSUS .TRACT <br /> Owner's Name Clarence Dpi Dulk Phone <br /> Address R D.+I "City CA-rlisle,: Penn. <br /> Contractor's Name Hennings' Bros . Drilling Co. , Inc " ' ' License # 290813 Phone 522-1031 <br /> TYPE OF WORK (Check): NEW WELL ,X" DEEPEN '/7 RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT T7 <br /> Other /% <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Old Well <br /> -� PROPERTY LINE -- PRIVATE DOMESTIC WELL:' PUBLIC DOMESTIC.WELL 100 t p . <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation last <br /> Domestic/private Drilled Dia. of Well Casing st <br /> ► " Ggdof CasfF__—• 1Ga Driverg - - --.. Q <br /> Irrigation S Gravel Pack Depth of Grout Sea]. I_ <br /> Cathodic Protection 7= Rotar TQ <br /> y ype of Grout unite <br /> Disposal - Other Other Information ' ' <br /> Slab by_owner <br /> Geophysical <br /> Surface Seal 'Ins talled 'B : 'Driller <br /> PUMP INSTALLATION: Contractor <br /> Type ;of Pump F H.P. . <br /> PUMP REPLACEMENT: /7 State Work Done - <br /> PUMP ,REPAIR: / / 'State Work Daigle <br /> i <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 i <br /> WELL DRILLERS REPORT of the -yell 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 L FOR A ,GROUT IN PECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ii LING CO. INC. TITLE ECT'YTBKPk <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I :. <br /> APPLICATION ACCEPTED BY <br /> " ,S. DATE I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE t57L. 7_ INSPECTION BY DATE <br /> iir 7420 na., 1'-')i.� ' - 1.I.2e nu 1 <br />