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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.2/,�CcU <br /> THIS PERMIT EXPIRES 1 YEAR FROM •DATE ISSUED , Date Issued /i e 71- <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 /> 'J'OB ADDRESS/LOCATION ;Z j7S - L.ON F. CENSUS TRACT '- <br /> Owner's <br /> RACT '-Owner's Name JOHN IEhRA Phone - 838-7462 <br /> Address 22075 E. LONE 'FREE RD. City ESCALON CAL <br /> Contractor's Name Rennin s 'Bros. Drilling C License #11 3;)-P Phone 522•-2'61+a <br /> [.-:TYPE,.OF,WORK "(Check)-:ANEW-WELL,. iX�- DEEPEN---/-- OND.ITIONY/? AESTItUCTIONyJ �_Y _ <br /> PUMP INSTALLATION /_/ PUMP,-RLPAIR / / PUMP REPLACEMET ;N __ <br /> -----Other / / f "" I .f <br /> 1f <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia'. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigationGravel-Pack—JDepth of Gro <br /> ut Seal <br /> _ <br /> Other r �. Rotary !r Type. of Grout�` ` <br /> Other ' Other Information <br /> PUMP INSTALLATION: ' Contractors <br /> ; Type of Pump Jl' H.P. <br /> F - <br /> PUMP REPLACEMENT: ` / J7State-`W&i bone_'r <br /> PUMP REPAIR: / I- <br /> State Work Done <br /> ��"' ESTRUCTIONTOWill,11M-a—me ter'-'""'� s� -Appto imate "Depthh"" <br /> Describe Material and Procedure <br /> I hereby agree to coiijl*iwith'rd11 laws and regulations of the San Joaquin Local Health District <br /> and the State of Caiiforiii'a'per.faining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of �M-y work' 6ii a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the ±beak of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t <br /> FOR DEPAATIJENT USS bI�LY-_ ____ _. _.-_ .'_ --••-- -._ ___.. . ._ <br /> I PHASE I <br /> f. APPLICATION ACCE_PT_E DATE ^ <br /> ADDITIONAL COMMENTS: _..w_ <br /> E <br /> PHASE,,jI GROUT INSPECT P F NAL INSPECTION <br /> INSPECTION BY DATE - 2INSPECTION BY JiL DANE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M G <br /> t <br /> t-- <br />