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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE "OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. � u <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM& Permit No. 777-?S%A/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x,-I- 7-77 <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. i <br /> JOB ADDRESS/LOCATION 20 50 MC HENRY AVE. & WIGLEY AVE .(DIRT ROAD kENSUS TRACT <br /> �' Ah ROLLINS 600= WEST OF MC HENRY,� SOUTH SIDE OF 8 .2936 <br /> Owners Name WIGLEY AVE . 83 <br /> Address 20550 :MC_ HENRY AVE. ;I City , ESCALON <br /> Contractor's NameHENNINGS BROS. DRILLING CO. i INC. License # 290$13 Phone 522-1031 , <br /> =0 W. RUMBLE RD.,3, MTD.- <br /> TYPE <br /> DTYPE OF WORK (Check): NEW WELL A7 -.,DEEPEN /7.. RECONDITION ..j-7 DESTRVCTION /7 <br /> PUMP INSTALLATION /_7 PUMP REPAIR / /, PUMP REPLACEMENT. f7 y <br /> • Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ��l2' ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL OM <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ;Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domeatic/public ' Driven Gauge of Casing 2 j <br /> Irrigation ' Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection X_ Rotary -Type of Grout ,Q <br /> p Disposal Other Other Information SUB-BY_O=R�, <br /> Geophysical Surface Seal Installed B DAILIM,. <br /> P014P INSTALLATION:. Contractor v WAX, -- /in -7 <br /> T „ L Type of Pump .. H.P1• <br /> PUMP REPLACEMENT.: / / State Work Done <br /> a <br /> PM rREPAIR: / State Work Done <br /> DES-IRUC.TION OF WELL: W Diameter Approximate Depth <br /> De s!y i e Mat Tial and Pocedu <br /> I- hereby agree to comply with all laws add regulations the San Jo <br /> nuin Local Heart District <br /> i-_. <br /> and the State of California. pertaining to or regulating• well,-costruction. Within FIFTEEN DAYS <br /> afte 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 GRO INSPECTION <br />' PRIOR 0 GROUTING AND A FINAL. INSPECTION. <br /> SIGNED <br /> I 1 INC . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEt&YMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ABY DATE , <br />` ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTXON i, [j_ � '� , PHASE FIN SPETI <br /> INSPECTION Bt, D E ,�. NSPF,CTION` BY DATE //,I-vz Ar <br /> Z <br /> �-• _ s /7 7 /� // <br />