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SAN JOAQUIN.LOCA.L HEALTH DISTRICT <br /> F'OSrOFFICE 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 -�-7c� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Realth 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 /> 1 <br /> JOB ADDRESS/LOCATION Von G1ahn Rd.- 4 Miles West of Escalon off Hwy 1 CENSUS TRACT <br /> - I <br /> Owner's Name Sherwood F'ranscella Phone 982-0570 <br /> Address _ - 15711 Due Rd. CityEscalon <br /> Contractor's Name Hennings Bros.. Drilling Co., Inc. License # 290813 Phone 522-1031 <br /> 25QQ Bumble Rd. Modesto Cal. 95350 <br /> TYPE OF WDRKCheck): NEW WELL /� DEEPEN ?'/ - - � �.. � ; y.-.=�.,. <br /> ( T RECONDITION /-T DESTRUCTION F <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD 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 Well. Excavation 11" <br /> Domestic%private - - Drilled Dia. -of.Well'Casiag 6 � <br /> - Domes tic/puuit r _ "� Driven " Gau e of'Cas iizg _ 30 aa <br /> Irrigation Gravel Pack Depth of Grout Sealr <br /> Cathodic Protection _ Rotary Type of Grout _�ento�mte,,.,_. W, ; <br /> Disposal _ Ocher Other Information S1R.b by owner^� <br /> Geophysical Surface Seal Installed By.0 Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Slate Work Done <br /> .PUMP .REPAIR: /7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter N Approximate Depth IWS&-Co( <br /> Describe Material and Procedure Co-seGce. _ <br /> I hereby agree to comply with all JLaws and 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 EUTING AND FOAL INSPECT <br /> SIGNED �� TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7`7 <br /> E H 1426 Rev. 1--74 <br /> 1-74 2M <br />