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SAN JOAQUIN LOt_L-119ALTH DISTRICT <br /> FOE OFFICE USE: �"� 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> _ZZ-', <br /> /_1 f Telephone : (209) 466-6781 <br /> j j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, !eJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 7-(C'V X09 <br /> Application is hereby made to the San Joaquin Local Health District for a permit tea 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 Harold Rd. � Mile So. of EScalon-RiverbanbEgi'y TRACT <br /> Owner's Name Craig Davis Phone 527-1316 <br /> G/0 JIM liaVIS , inr,. <br /> Address ____1938 Main City Es talon, Cal. <br /> Contractor's Name HENNINGS BROS. DRILLING CO, 2 INC. License # 290813 Phone _522-10.31 <br /> 2500 West Rumble Rd. Modesto Cal. 95350 <br /> i <br /> TYPE OF WORK (Check) NEW,WELL_./ DEE_P_EN / f RE_ CONDITION ./ /_ DESTRUCTION ./'? <br /> f PUMP INSTALLATION/ I PUMP REPAIR) I PUMP REPLACEMENT 17 <br /> Other / / — <br /> DISTANCE TO NEAREST:A EPTIC TANK ,r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS OOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <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 6 2ff <br /> Domestic/public Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection Rotary Type of Grout _ Bentonite <br /> Disposal Other Other Information slab by Owner <br /> Geophysical. Surface Seal Installed By: <br /> RUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PlfMT REPLACEMENT: / / State Work Done <br /> PUMF .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 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 Chem 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 HENNTNGS BROS. DRILLI115 CO. INC. opv BKPR <br /> Al D W PLOT PLAN ON RE E SIDE .I; <br /> OR DEPARTMENT USE NLY <br /> PHASE I <br /> APPLICATION ACCEPT 4,4LI/�t� DATE T Z r <br /> ADDITIONAL COMMENTS: <br /> PHASFW I GROUV INSPECTION P ,IFINAL INSPECTI <br /> INSPECTION BYATE - /3- 7� INSPECTION B j? DATE <br /> fid? 3/76 2M <br /> E H 1426 Rev. 1-74 <br />