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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHrOFFICE USE: ii1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7fG-33DLc� ' <br /> THIS PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED Date Issued v1'-,.254-7P' <br /> �M. (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 :Wade in compliance with San Joaquin., <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> 4F7`fe E. �Q,�7�i�c� �� -. 22S-oeo `�c7 <br /> JOB ADDRESS/LOCATION East Arthur & Brennan CENSUS TRACT <br /> qqI 4 <br /> Owner's Name Joe Bylsma li Phone 838-7448 <br /> Address 24065 Ea Arthur City Escalon, Cal. <br /> Contractor's Name Hennings 'Bros. Drilling Co., Inc. License #290813 Phone 522-1031 i <br /> 2540 W. Rumble Rd. Modesto, Cal. <br /> TYPE OF WORK (Check): NEW WELL /X-7 DEEPEN/_7 RECONDITION /_7 DESTRUCTION+J7 ~ <br /> PUMP,fINSTALLATION / / PUMP REPAIR /-7-pump REPLACEMENT <br /> Other / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> .x <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cable Tool Dia. of Well Excavation <br /> I Domestic/private j. / Drilled Dia. of Well Casing — <br /> Domestic/public Driven Gauge of Casing 12m <br /> Irrigation . Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout Bentonite ; <br /> Disposal Other Other Information . _Slab by—omar <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 /> ESSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l I hereby agree to comply with all laws and regulations of the San Joaquin' Local Health District <br /> And the State of Californialpertaining 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'lwell 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 UTING AND AFINATj INSPECTfON. <br /> SIGNED TITLE <br /> (D T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLX <br /> PHASE I Fr <br /> APPLICATION ACCEPTED BY DATE 6-1 8--Z 4- <br /> ADDITIONAL <br /> - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT!; INSPECTION P E I FINAL INSPECTION <br /> INSPECTION BY iM DATE 6=V T�=.2 y INSPECTION- BY DATE _ n=14-74 <br /> EH- 1426 Rev. 1-74 i� 1-74 2M <br />