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SAN JOAQUIN'I.00AL. HEALTH DISTRICT i <br /> FflE OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif_ <br /> v Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Ispugd 3-/o-77 i <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. <br /> p <br /> JOB ADDRESS/LOCATION River Rd. Mile West of McHenry Escalon <br /> %'�� � ! ,� <br /> dge- -Us•t paw .a CENSUS TR4CT <br /> Owner's Name Frank BaVarQ north Side Phone 838-2b51` J <br /> Address 265312. East Jones <br /> City Escalon Cal. <br /> ► <br /> Contractor's Name HENNINGS BROS. DRILLING,CO. , INC. Licen a 29083 phone ,5221031' <br /> . ...: . <br /> 2500 es um e e o, Cal. 9535 . <br /> . � <br /> TYPE OF WORK (Check); NEW WELL )T/ DEEPEN /_� RECONDITION /� DESTRUCTION <br /> 51 <br /> PUMP INSTALLATION / /, . PUMP REPAIR /.7 PUMP REPLACEMENY /'7 <br /> Othei / / ¢ — a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPfAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ,:�0 `= PUBLIC DOMESTIC WELLw <br /> INTENDED USE TYPE OF WELL CONSTRUCTI4N 'SPECIFICATIONS' t <br /> Industrial " Cable Tool Dia. of Well. Excavation 12rr <br /> TL Domestic/private �' Drilled Dia. of Well Casing - <br /> Domestic/public Driven Gauge of Casing e',` <br /> Irrigation -.,Gravel Gravel Park Depth of Grout Seal <br /> Cathodic Protection r Rotary Type of Grout Bentoni. e <br /> Disposal Other Other Information BlalD 'by 'owner' ` <br /> Geophysical <br /> Surface Seal Installed Bytom' <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type-of- Pump .5ce 1, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR /_� State Work Done <br /> bESjRUCTION OF WELL: Well Diameter Q�ximate Depth <br /> Describe Material and race ure —` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health istrict <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 REP of the well and notify there 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 />?$IO.R TO ROUTING AND A F NAL INS EGTION. : <br /> (D PLOT P ON REVERSE I�IE <br /> ' FO DEPARTMENT USE O LY J <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT$ <br /> ADDITIONAL COMMENTS: <br /> FUSE TGRWUT INSPECTI N PHAS III IN IN PECTJON <br /> INSPECTION By ! DATE �'�/� INSPECTION BY DA <br /> -E x 2t; mi 2 l� 1/77 9 <br />