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SAN JOAQUIN LOCAL HEALTH DISTRICT B.7,-- <br /> OF OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <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 (1/_/_?-7� <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 /> l County Ordinance No.1 .1862 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.,SOUTH END OF SEIDNER AVE . , : SOUTH OF HWY 1 209ENSUS TRACT <br /> Owner's Name ' AGRO !NCORP. WEST SIDE <br /> Phone 838-7624 <br /> Address.,' '1 7202 STEINEGUL RD'. . City,y ESCALON <br /> Contractor's Name HENNINGS BROS. DRILLING COY-1 INC? License # 290$13 Phone '545-118 <br /> :Z52.5 PELANDALE AVE.* NQUESTO- <br /> TYPE OF WORK (Check) : . NEW ,WE7 L ,-/1 DEEPEN__/�/__RECONDITION ./, / w DESTRUCTION <br /> PUMP, INSTALLATION / / PUMP REPAIR-,,'/, / PUMP,,REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE AISPOSAL FIELD f CESSPOOL/SEEPAGE PIT OTHtR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -_ PUBLIC DOMESTIC WELL c/). <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! <br /> Industrial I Cable Tool Dia', of Well Excavation 1111 <br /> X Domestic/private ' ; Drilled Dia, of Well Casing 611PLASTIC <br /> Domestic/public Driven Gauge of Casing 160 WA LL <br /> Irrigation >X 'Gravel Pack Depth of Grout Seal 50, <br /> Cathodic Protection ' JX Rotary Type of Grout BENTONITE <br /> Disposal y� Other Othei Information SLAB-BY OWNER <br /> Geophysical .. Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor 78-4.7 0 <br /> Type "af Pump �' H.P. <br /> PUMP REPLACEMENT: f <br /> LL State Work Done <br />-PUMP - <br /> / / State Work Done " <br /> DESTRUCTION OF WELL' Well Diameter v CJ <br /> -��, ._1? T�l�� Approximate Depth <br /> Describe Material and Procedure �c_K.U/ 4105 <br /> I hereby agree to comply with Pall jl.awslland 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 <br /> WELL DRILLERS REPORT of the well 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL 2NSPECTIUN. <br /> SIGNED HENNINGS BROS . DR . I IHC . .", BY TITLE <br /> Qeaeu <br /> 1 (DRAW PLOT PLAN€bN REVERSE- SIDE) <br /> j POR;,DEPARTMENT USE{ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE �2 <br /> q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ill /FINAL INSPECTION, <br /> INS�P€ CT .ON BY ' ly DATE /, '76 <br /> E1 � DATE / INSPECTION BY <br /> k60E H 14v r, 1 7 4 .. l/ �J1f� 0-t9t L�, <br /> -�-- - Nd ZnrSf,.rcG7/e. �.,s ir//�. c DN.�+ v1 <br />