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'< SAN JOAQUIN LOCAL HEALTH DISTRICT DA� / t <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Ay <br /> Telephone : (209) 466767$1. be"V 614" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '! f9 6 f� <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION JnZ •.. _.E,t s WEST OF CARIGNANE AVE ., 501 'SOUTZNSUS TRACT 225 X40 !y <br /> Owner's Name CITY OF ESCALON OF TOKAY AVE . i ESCALONPhone <br /> Address CITY CLERK, CITY HALL City ESCALON <br /> Contractor's Name HENNINGS BROS.- DRILLING CO j INC . License # 290813 Phone 545-1185 .� <br /> / 13525 PE LANDA LE TVE.------------------------------ — <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /K/ DEEPEN / / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /. / <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY -LINEN f PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ �Cab le Toal Dia. of Well Excavation 21e.r F <br /> Domestic/private Drilled Dia, of Well Casing 1211 - <br /> Domestic/public Driven Gauge of Casing 3/16 GA <br /> Irrigation X Gravel Pack Depth of Grout Seal. 601 T <br /> Cathodic Protection Rotary Type of Grout 2611 conductor & cement <br /> Disposal X Other REVFRSE Other Information Slab-by Owner <br /> _Geophysical ROTARY, Surface Seal Installed By. driller <br /> l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' 3 <br /> PUMP REPLACEMENT: -/ _/State Work Done <br /> 7;/(V -7? <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San. Joaquin Local Health District <br /> and the State of.• California'pe-rtaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a r <br /> WELL DRILLERS REPORT of the well arid--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 HENNINGS BROS. DRILLING INC . BY TITLE �" SEC`. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE )�Iyl/FIN4LINSPECTION <br /> INSPECTION <br /> BY DATE INSPECTION BY DATE r' <br /> E H 1426 RPv_ , --7L e6 <br />