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•� .. . l <br /> SAN JOA.QUTN-LOCAL HEALTH DISTRICT <br /> F0T� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SCANNE4 oq 1,0 ' <br /> Telephone: (209) 466 .6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 o1p?� W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-1a 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Hemlth District for a permit to construct <br /> and/or install the work herein described. This ap location 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 p qa�5 E _Orn n gp Ave_#-10001 West of Henry Ave.OSUS TRACT <br /> north side <br /> Owner's Name Tailher Johnson Phone 838-781.0 <br /> Address 29855 E. Orange Ave. City Escalon j <br /> Contractor's Name He n3n�s_grosnril� Iii Sf ,,:�Ir-g_a License # 290813 Phone 22.-1081 � <br /> 2 500 W. Rumble Rd.. d ; ► � <br /> TYPE OF WORK (Check); NEW WELL -/-7 DEEPEN /7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR/-7 PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER /O� QQ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL ' A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11'x' <br /> X Domestic/private Drilled-- - Dim._ of-We11-Casing r� last c= =- <br /> ._Domestic/p`-uFjie _ Driven Gauge of Casing 160 Wall .{ <br /> Irrigation X Gravel Pack Depth of Grout- Seal 501 i <br /> Cathodic Protection _ Rotary Type of Grout ' Bentonite 1 <br /> Disposal Other Other Information slab�by owner <br /> Geophysical Surface Seal Installed 'By: 'driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _7P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP �REPAIR: / J State Work Done G� <br /> TRUCTION OF WELL: Well Diameter �r Approximate Depth _5-0 { <br /> f Describe Materal and PrOcedur <br /> I hereby agree to comp with all laws and regulat ons of the San JoArquilp Local Health District <br /> and the State of California pertaining to or regulating well •'construct_i n. Within FIFTEEN DAYS .„ <br /> after completion of my work on a new well,-,I,wih--,furnish the San - quin Local Health District a <br /> WALL DRILLERS REPORT of the well and notify them before putt3.ng.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 ARD A FINAL INSPECTION. SEC. <br /> °.TONED KENNINGS BROS. DRILLI INC . BY TITLE 21L eddu <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br />', PHASE I <br /> I APPLICATION ACCEPTED BY DATE <br /> r ADDITIONAL COMMENTS: . <br /> PRAW 41 g2UT, INSPEC=L7z- <br /> PHA Y IN INSPECT N <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> .V 17 '11.74 4�o// //n.! -,. ." '! 1./7K W <br />