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f <br /> SAN JOAQUIN&0GAL- HEALTH DISTRICT <br /> FOF OFFICE USE: Ppr 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �r 'z,/ <br /> (Complete In Triplicate) <br /> Application is hereby made to the 'San Joaquin Local Health District for a permit to construct <br /> i 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 Lathrop Rdoo- 00t West of CottagesouthCENSUS TRACT- Rd. Y <br /> - t side <br /> Phone 2-�9-2 <br /> Owner's Name A. S andrio Maatecn <br /> 9 -_ <br /> Address 7272 E.]Lathro :,Rd. City <br /> ( Tn License # 290813Phone ' 2-1 031 <br /> Contractor's Name -Rennin Bros,- Dr'i.11in CO. <br /> 2 00 W: Rumble Rd Mad'. <br /> TYPE OF WORK' (Check) : NEW WELL /X/ DEEPEN/ / RECONDITION /� DESTRUCTION /^T <br /> PUMP INSTALLATION /_/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK QOM SEWER LINES �QQ'' - PIT PRIVY , <br /> A <br /> SEWAGE DISPOSSAL FIELD %01+ CESSPOOL/SEEPAGE 'PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> t INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation jjtl \ <br /> X Domestic/private Drilled Dia. of Well Casing _ 6-5/$t' <br /> Domestic/public Y Driven Gauge' of Casing- 1 ( A _ <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 Owner <br /> Geophysical Surface Seal Installed By: driller__.. <br /> 4. UMP INSTALLATION: Contractor C/L <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / w State Work Done <br /> PUMP .REPAIR: r / / State Work Done <br /> # -30 <br /> DES-TRUCTION OF WELL: Well Diameter " f Appro mate Depth <br /> Desc ibe Material an rocedure <br /> zvt�w -4.0--Qr <br /> I hereby agree to comply with all laws an egu ions of the Sian .Joa4fuin 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to thelbest of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. INC. BY TITLE SE.C. <br /> SIGNEDRI ING . 9 _ <br /> cv (DRAW- PLOT PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> ! PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> t PHAS I GR T- INSPECTION PHASE IY/FINAVINSPECTIQ <br /> INSPECTION BY DATE F-/d-7 6 _- INSPECTION BY DATE <br /> 76 2m <br /> E H 1426 Rev. 1-74 <br />