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f <br /> 'SAN JOAQUTN LOCALHEALTH DISTRICT <br /> FO_.OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209') 466 .6781 <br /> PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f 2-01-2J,+ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1L/�,S 7� <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. 186.2 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I mile west of McHenry on S. side of JoneCENSUS TRACT <br /> Owner's Name Rollins Ranches Phone 838--2936 <br /> t <br /> Address 20550 S.iMcHenry, Escalon City ' I <br /> Contractor's Name Howk Well & Equipment Co. Inc. License # 2105 .2 Phone <br /> TYPE OF WORK (Check): NEW WELL /g DEEPEN/7 RECONDITION /-7 ' DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 001 SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> R d PROPERTY LINE - PRIVATE DOMESTIC WELL:.,3401 PUBLIC DOMESTIC WELL 9`y <br /> INTENDED, USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation 21,'1 <br /> Domestic/private Drilled- Dia. of.Wellgis r gr�. <br /> Domestic/public Dr1Ven _ Gauge o huasing _ .219 �}' <br /> x Irrigation x Gravel- Pack Depth of Grout Seal �; <br /> Cathodic Protection x - Rotary Type of Grout. <br /> Disposal Other Other Information <br /> Geophysical Surf ace'Seal Installed By. <br /> PUMP INSTALLATION: Contractor Howk Well & Equipment Co,—.4—Ing. <br /> <� <br /> Type.-of..Pump_ Enine driven_ vertical toreH.P. 1 on <br /> :n� <br /> PUMP REPLACEMENT / / State Work Done <br />. - s•,wT-x-�a�r..�aE,.�.is"-a,^"�,.�'�.y�....r.�-.�."" ,a-�.�. �..,r�o++�..... <br /> Pt9MP- REPiAIR-- T/=/ �-State Work Done <br /> DESTLUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of nay work on.a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLER# REPORT of the well and notify them before putting.-the.-well in.use.... .The above <br /> informatio true -best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING AN A , INSPECTION. <br /> SIGNED 'TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) /Vi e P <br /> DEPARTMENT USE ONLY <br /> iPHASE I <br /> APPLICATION' ACCEPTED BY e DATE ' <br /> ADDITIONAL -COMMENTS., <br /> PHASE II GROUT INSPECTION PHA III IN AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <" <br /> } r <br /> L <br /> E H 1426. " Rev. 1-74 —� ,` X1175 2M <br />