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SAN J©AItIN LOCAL HEALTH DISTRICT <br /> FOR!OFFE USE; =' - 'r 601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone: (209) 466-6781 <br /> :-�� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <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 SaVk Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. �; - . CENSUS TRACT <br /> Owne* is Nance StanleyLove, Jr. Phone 838-2686 <br /> Address 21 49 E . River Rd. _._ City Escalon - - <br /> f Contractor's Name °rennin s Bros . Drilling -Co.jnc. License # 290813Phone 522-1039, <br /> 2 00 W. Rumble Rd. Modesto <br /> r <br /> TYPE OF WORK (Check)., NEW WELL ./X7 .DEEPEN '/7 RECaNDITI,ON / DESTRUCTIOR,-r7 <br /> ALLAT <br /> 'PUMP INSTION / / PUMP REPAIR i-7—pump REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK > 5--5-1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD :Ss ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.`LINE -- PRIVATE DOMESTIC WELL ' - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. '� ` Cable Tool Dia. of Well Excavation12rt <br /> -X. Domestic/private Drilled Dia. of Well Casing 11 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack � Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout Ronton-i.te y <br /> Disposal Other Other Information f;1 ab-bX owner. , <br /> Geophysical - - �- Surface Seal Installed BY: r .. r� <br /> C <br /> PUMP INSTALLATION: Contractor : <br /> Type of iPump H.P. <br /> PUMP REPLACEMENT: /_7 State .Work Done <br /> PUMP_REPAIR-:---�- -­/7—•State-Mork Done <br /> PES-TRUCTION 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 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—th-em'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 I SPE CTION <br /> SIGNED J a. TITLE <br /> (DEM PLOT LAN ON REV SE SIDE <br /> I sFOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z S <br /> ,ADDITIONAL COMMENTS: i <br /> P E tW GROUT INSPECTION k PHAIWXINAL INSPECTION <br /> INSPECTION BY DATE 'g INSPECTION BY - DATE <br /> E H 1426 Rev. 1.-74 �. ' { 1-74 2M <br />