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__ - <br /> �� SAN JOAQUIN LOCAL HEALTH DISTRICT /p <br /> FOE OFFICE USE: 1601 E. Hazelton Ave:; 'Stockton, Calif. �b / `)^;7 ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,& X2[41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 Mile East of Steingu.l on Lone Tree CENSUS TRACT <br /> Owner's Name Lydia Hall Phone 838-2224 <br /> Address 29601 E. Lone Tree Rd. City Escalon, Cal <br /> Contractor's Name Hennin s Bros. Drilling Co. , Inc . License 4290813 Phone522-1031 <br /> 250 West Rumble Rd. Modesto, Ca 95350 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-1 DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY 9, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PT&At DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 lrt <br /> .X_ Domestic/private Drilled Dia. of Well Casing 611 Plastic <br /> Domestic/public Driven Gauge of Casing 160W <br /> Irrigation Gravel Pack Depth of Grout Seal 50 T <br /> Cathodic Protection - X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information _ _,31ab by owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> .Describe Material a d Procedure <br /> I hereby agree to comply with all- laws-an regulations of the San aquin Lo Health'' strict <br /> and the State of California pertaining to or regulating we11''construction. Within FIF EEN 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 Hennings Bros . rl Ing o. ,Ine TITLE B 8/25/ <br /> DRAW P T PLAN ON REVERSE SIDE) <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PH4.SE IT GR UT INSPECTI2 PHASE II jFIN IN PECTIO <br /> INSPECTION BY ATE NSPECTTON BY 'F� _ DATE <br /> �! -S,�P�c�r,��'�- - <br /> E H 1426 Rev. 1-74 �'; amu- t-r� `3J7b 214 <br /> - i1/�`� peri✓}�{'r.Arif/ /uvre .4v /IQ,4 /fi �",�- 1�- <br />