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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I $IV' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]7- <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 2513 E. Wi le Rd.-between Jones & Meyers CENSUS TRACT ' <br /> L►esT OF IWC HewV OWE NO&A Si 66 <br /> Owner's Name Robert Cornwell Phone 869-3921 <br /> Address 25137 E. Wigley Rd.. City Escalon <br /> _ Drilling Go. sTnc. License # 2 081 Phone 22--10 1 <br /> Contractor's Name Hennings Bros. <br /> _2500 W. Rumble Rd.. Mod. <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR / J PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q, EWER LIN&-,- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation n <br /> X Domestic/private Drilled Dia. of Well Casing <br /> 'Domestic/public Driven Gauge of Casing _ 160 w 1 v" <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> f Cathodic Protection X Rotary Type of Grout Bentonite <br /> DisposalOther Other Information <br /> Geophysical' Surface Seal Installed B : d iller <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT J J State Work Done <br /> PUMP .REPAIR: . / / ,. State Work Done <br /> Mw <br /> DESTRUCTION OF WELL: Weli Diameter Approximate Depth ' <br /> - °"" ' —Desc 4bje Material and Pro edur/ <br /> r (/ <br /> 1a rco mply,„ ith aa,1-1' s and regulation of he San Joaquin ocal Real <br /> I hereby agree too h Distr t <br /> ,ad <br /> M the State of b. orn-ir pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> Comp my work on a new well, I will furnish the San Joaquin Local Health Distri a <br /> r <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 . . J INC. BY TITLE SEC <br /> „ DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I ' <br /> 01 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ` <br /> s. P E II ROU INSPECTION PHAS <br /> VFAAL NSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE _f <br /> ✓ 3/76 2M <br /> a . F. 14 1426 Rev.w 1-74 �� _. <br />