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f� L"-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: V X1601 E. Hazelt'6i Ave . , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZI• 41{ <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/ox install thework herein described. This, application is made iii compliance with 'San Joaquii <br /> County Ordinance No. 1862. and the Rules and. Regulations of the San Joaquin Local Health District. <br /> f F <br /> JOB ADDRESS/LOCATION ;.1 M V[E T OF BRENNAN RDF NSUS TRACT <br /> --MI.. NORTH OF LONE TREE RD. <br /> ' Owners Names TONY ROCHA JR. Phone 838-2521 <br /> Address - 2 23 #LONE TREE RD. <br /> x City ESCALON <br /> Contractor's Name IH.ENNINGS BROS. DRILLING CO. INC. License # 29081 hone 545-1185 <br /> =.=.==..3525 PELANDALE AVE. MOD. CA. 953-50 <br /> TYPE OF WORK(Check) : NEW^ WELL 1 DEEPEN _3 <br /> RECONDITION '/~ / DESTRUCTION /_7 - <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /_ W <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .9 5t. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL —.._. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A. Cable Tool Dia. of Well Excavation 1 sa <br /> Domestic/private !I Drilled Dia. of Well Casing :t PLASTIC <br /> Domestic/public I{ Driven Gauge of Casing 160 WALL <br /> Irrigation 11X Gravel Pack Depth of Grout Seal _ Ot <br /> Cathodic Protection I X Rotary Type of Grout BENTONITE <br /> Disposal Il Other Other Information SLAB-BY OWNER <br /> Geophysical ' Surface Seal Installed B : DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Typeof Pump H.P. <br /> PUMP REPLACEMENT: / / iState Work Done <br /> PUMP .REPAIR: � •� <br /> . / / !State Work Done_ <br /> DESTRUCTION OF WELL: Well ',Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> J <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 dell 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 . 'INC . BY TITLE <br /> '1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE` <br /> ADDITIONAL COMMENTS: �► <br /> PHAS GROU INSPECTIO PHASE /FI"DATE <br /> INSPECTION BY ATE 7 INSPECTION BY <br /> `E H 1426 Rev. . 1-74 �/ 01 x" 2M <br />