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r - - <br /> ; n <br /> vh k3 SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No. 77 l�i�J <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �,�_�) a <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 /> JOB'ADDRESS/LOCATION ,!-m Wer, CENSUS TRACT <br /> Owner's Name William Hale side <br /> y Phone 838-3214 <br /> Address 16829 S. Seidner .Rd. city Escalon <br /> Contractor's Name-- Hennings Bros. Drilling Co. }Inc. License # 29081 hone 522-1031 <br /> 2500 W. Rumble R .. Mod. <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> ;..� ._ other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j0ell-tk-4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 11' <br /> X Domestic/private Drilled Dia, of Well Casing _=P astic <br /> Domestic/public Driven Gauge of Casing 160 Wall <br /> .Ir.rigation _ -"_ -_"___Grave-l=Pack-- —Depth -of--Grout-Sea-l­ <br /> Cathodic Protection - K- Rotary Type of Grout B enfonl e <br /> Disposal Other Other Information -Slab-by owne r <br /> Geophysical Surface Seal Installed By: driller <br /> PIWP INSTALLATION: Contractor <br /> = Type of Pump H.P. <br /> PUIP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /Of �S 7 Work Do e <br /> jN14` <br /> DESTRUCTION OF W We �l`Diameter Approximate Det <br /> . ':., <br /> _5, Describe Maters l and Procedure <br /> I her-eby, agr a to comply with all laws 7d <br /> regulations o t e 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 use. The above <br /> informa4.ori is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS . DRILL . INC. BY TITLE EC. ` <br /> n W� PL T PLAN ON REVERSE SIDE <br /> OR DTMENTIJSE ONLY <br /> PHASE I <br /> APPLICATION .ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS: <br /> r PHA T INSPECTI N PHA I / NAL NSPECTIO <br /> INSPECTION B� DATE INSPECTION BY e4DATE a <br /> 1413 <br /> 3/76 2M ; <br /> E H 1426 Rev. 1-74 - -. <br />