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- SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FO-- OFPICE USE. 1601 E. Hazelton Ave--,Stockton, Calif. <br /> Telephone: 4<209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5 _3SS!-✓ <br /> [ ( / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued sl- 7--717 <br /> (Complete In Triplicate) � <br /> Application is Aereby 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 278 LONE OA _RDS-E1D OF ROAD_, EAST OF CENSUS TRACT <br /> SEXTON AVE. , SOUTH S IDE <br /> Owners Name JAMES L- C49ATEO Phone 47aa. 838-»3691 <br /> f <br /> Address T 23278 LONE OAK..RD. _ ---- City ' ESCALON. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. 9INC. License # 29081 bhone - 522-10311 <br /> 2500 W. RUMBLE RD.j TIUD. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /X7 DEEPEN /'7 RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK `JS/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD q 74- CESSPOOL/SEEPAGE PIT OTHER UZZ4 gip' e <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � �} <br /> INTENDED USE TYPE OF WELL CONSTRUCTION S EC FICA IONS . <br /> Industrial Cable Tool Dia, of Well Excavation 1jtl <br /> -XDomestic/private . __ _ _ Drilled - _ Dia. of Well Casing 611 kLA4 <br /> � .,. <br /> Domeptic/public Driven Gauge of Casing j 6�} <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout EENTQNITE <br /> Disposal Other Other Information .. <br /> - Geophysical Surface Seal Installed B R ILLE,R <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -,REPAIR: / / State Work Done <br /> 6DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> � D s rib- Mat xial d Procedure <br /> I hereby agree to comp y with all la`s and regu�at ons of t a San Joaquin Local Health istxfct <br /> and the State of California pertaining to or regulating well"construction. Within FIF7EEN 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 GROg INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED LING CO. INC. BY TITLE y. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> OR ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE !' <br /> ADDITIONAL' ' CQMMENTS: <br /> PHA,%E 41BW- INSPECT12N PHASE III FINAL INSPECTIO <br /> INSPECTION BY. a DATE Iff7 INSPECTION BY DATE <br /> '/ r . <br /> r Al �,9p; i'na!-l7cx„F vc,y� <br /> E H 14.26 Rev. 1-74 %fc�{dee- caul '=�-��= ``'fid(,Ur// .' 1/77 - 2H <br />