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/ # <br /> SAN JOAQUIN LOCAL- HEALTH.DISTRICT <br /> FOROFFICE USE: 1601_ E. Hazelton Ave., Stockton, Cali t` <br /> A D. �� Telephone: (209) 466--6781 1 <br /> ,'"APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued " I� <br /> - (Complete In Triplicate) <br /> Application is tereby,/made to the San Joaquin Local Health District for a permit to construct <br /> and/oi install the work herein described. This application is made in compliance with San .L .aquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONIJARQT.T) SUS TRAGI t <br /> NORTH SIDE <br /> Owner's Name `JOHN BELLING Phone <br /> Address 27093 E. VINE AVE. City ESCALON � <br /> Contractor's Name HENNINGS BROS. DRILLING CO..EINC. -License # 29r0813 Phone 54 -11 $ I <br /> 1525 PELANDALE AVE. MOD-W/';1% ' <br /> TYPE OF WORK (Check): NEW WELL ,&-7 DEEPEN RECONDITIONI-T DESTRUCTION /_7 '+ <br /> PUMP INSTALLATION / PUIP REPAIR / / PUMP REPLACEMENT %7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD s CESSPOOL/SEEPAGE PIT OTHER WEU.-30 =V <br /> PROPERTY LINE - PRIVATE MESTIC WELT, � PUBLIC DOMESTIC WELT. C', <br /> ,INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r� co <br /> Industrial : Cable Tool Dia. of Well Excavation <br /> ., <br /> Domestic/private Drilled Dia. of Well CasingON <br /> �� d <br /> Dowstic/public Driven Gauge of Casing 3. <br /> Irrigation Gravel. Pack Depth of Grout Seal � t <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab-by owner <br /> „ Geophysical - Surface Seal Installed B driller - - <br /> _. . <br /> PUlT INSTALLATION: Contractor <br /> Type. of Pump - ✓� p ,� U.K._=;?.. <br /> PUMP 1KPLACBMENT: - / / State Work Done $v <br /> ptV :SBP <br /> NOF We11 Diamet F/� :1 Approximate Depth <br /> De cribe Material <br /> a Procedure <br /> r�;�' . � <br /> �Lereby agree to comply with all la 'and regulation of the San 4uin Local' EbOlth District i <br /> ajid _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 INSPECTION. <br /> SIGNED HENNING8 BROS. DRILLIN . INC. BY TITLE � � <br /> DRAW PLOT PLAN ON REVERSE SIDE} <br /> R DEPARTMENT USE ONLY <br /> PHASE I c , <br /> APPLICATION ACCEPTED BY DATE e7l 1_X <br /> Sw <br /> ADDITIONAL COMMENTS: <br /> ` PHASE AGROUXINSPECTIOW PHASE III12INAL INSPECTION <br /> INSPECTION BY ATE Z. INSPECTION BY DATE <� �` <br />