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T _ 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 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 i YEAR FROM DATE ISSUED <br /> Date Issued ,-J_3 <br /> (Complete <br /> Application is hereby made to the San Joaquin, Local Health District for a permit to con <br /> and/or install the work herein described. This application is made in compliance with San uJoa ui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Districts <br /> JOB ADDRESS/LOCATION jq401:. S DAITI3TN <br /> CENSUS TRACT <br /> Owner's Name . LE7NARD DAHT,TIV <br /> PhonLP38-29 54 <br /> Address STN .RD <br /> City ESCALON <br /> Contractor's Name T .D. <STTr0nV Ai�M) SQTT <br /> License. # 2790 10 Phone 838-2207 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /_/ i' RECONDITION/-7 DESTRUCTION <br /> PUMP INSTALLATION - ' /? <br /> / PUMP REPAIR /r// PUMP REPLACEMENT /? <br /> Other <br />� / / <br /> DISTANCE TO NEAREST: SEPTIC TANK - I <br /> SEWER LINES PIT PRIVY ! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ � <br /> � <br /> z <br /> NTENDE -` �I <br /> D USE ,L TYPE OF WELL <br /> Industrial ,i ' CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private �. Drilled <br /> Domestic ` ' ' Dia. of Well Casing <br /> /public � � Driven-� Gauge of Casing <br /> Other <br /> r4 ' ,� Gravel Pack. Depth of Grout Seal <br /> Other - <br /> -�-- Rotary ` Type of Grout . <br /> Other ; Other Information <br /> PUMP INSTALLATION: Contractor �I <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> f <br />-L17-RE-PAI-R-. jV-=State-=Work Done I 'MOVE 1 <br /> REPLz4.0� :SUM � <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth f <br /> i <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 them before putting the well in use. The above <br /> information is true. to . a best of my knowledge and belief'. � <br /> SIGNEDb1 � <br /> (DRAW PLOT PLAN ON REVETITLE PARTNER <br /> RSE SIDE <br /> PHASE E I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , <br /> ADDITIONAL COMMENTS: DATE # <br /> PHASE II OUT INSPECTION P I zNAL INSPEC N <br /> INSPECTION BY �! DATE INSPEC B <br /> DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />