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•.=� SAN JQAQUIN: LOCAL HEALTH DISTRICT <br /> FOR r_ FICE USE: <br /> 601 E. Hazelton Ave. , Stockton, Calif. <br /> f,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> A I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> k and/or install the work herein described. This application is made in compliance with San Joa uin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.q <br /> JOB ADDRESS/LOCATION <br /> Owner°s Name 'CHARLIE BETTI CENSUS TRACT <br /> E Phone 838-7456 <br /> t Address 26605 E,- RIVER ROAD. <br /> City ESCALON, CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO., INC. <br /> 2500 W. RUMBLE RD. MODESTO, CALIF. License # 29081.3 Phone 522-1031 <br /> 0 <br /> TYPE OF WORK (Check): NEW WELL L_x7 DEEPEN -/_7 RECONDITION _ <br /> I_T DESTRUCTION /-j <br /> PUMP INSTALLATION /:/ PUMP REPAIR / / PUMP�REPLACEMENT % f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> •�t�r'U� �C CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WellExcavation 12„ <br /> �_ Domestic/private Drilled Dia, of Well Casing 8 <br /> , Domes:tic/.public.;.,�. .... <br /> Irrigation - —Gauge of Gasing,. a— <br /> _ Gravel. Pack Depth of Grout Seal 0� <br /> Cathodic ProtectionXRotary T <br /> Disposal `- Type of Grout BentoniteOther Other Information Slab b owner <br /> _`_,Geophysical --'---- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done ' <br /> PUMP '.REPAIR: /T State Work Done <br /> 0ES-TRUCTION OF WELL: Well Diameter , <br /> Describe Material and Procedure Approximate Depth <br /> l hereby agree .to comply with all laws and regulations of the San Joaquin' Loca1 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 use. The above <br /> information is true to the.bes't of my knowledge and belief. I WILL CALF. FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND FIN INSPECTION. <br /> SIGNED <br /> TITLE <br /> � PLOT PLAN ON REVERSE SIDE <br /> p�z _Q DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE �'• <br /> PHA E II GROUT NSPECTIO <br /> INSPECTION BYHASg III INAL MPEC ON <br /> DATE 7-/-7 y INSPECTION BY DATE Z. / J� <br /> E 526 Rev. 1-74 <br /> 1 <br />