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FOR�OFFICE USE.; <br /> SAD1 JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E• Hazelton <br /> Ave. , ,Stockton, Calif. �. <br /> � n Telephone: (209) 466-6781 WELL CONSTRUCTION <br /> ORP � . <br /> UMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES <br /> APPl 1 Y <br /> EAR PROM DATE ISSUED . <br /> kation is die" t (Complete In Tri Date issued <br /> xeby mace 'to the San Joaquin Lova] Health District f <br /> and/or install the work herein described. <br /> County Ordinance No.` 1 b2 a This.a <br /> th les n application is made inrcomPe t to eonstrucC" <br /> Dp Regulations of the San .Toa Pliance with San Joa <br /> JOB ADDRESS/LOCATION Ellis Rdo off Clow Joaquin Local Health Distr ctin <br /> Rd" mile west of Mcg <br /> Owner's Nam Lorraine Cantrell .TRACE <br /> Address 2008 Phone 838-.7?0 <br /> 7 Ella.s Rd, 9 <br /> Contra: • <br /> tor's Name Hennings Bos . City ES talon, Cal, <br /> g r Drilling'.Co,. <br /> 2 00 W Rumble ' nc" License !1290813 <br /> Rd Modesto C 1 0 Phone 522_1031. " <br /> HYPE OF WORK {Check): <br /> NEW WELL " <br /> / DEEPEN /? RECONDITION i <br /> PUMP INSTALLATION / / PUMP REPAIR /? DESTRUCTION ./ ,1 <br /> Other /,J // PUMP REPLACEMENT /7 <br /> -- .7 <br /> ISTANCE TQ NEAREST: <br /> SEPTIC TANK SEWER LINES ,. <br /> .SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSSSPQOL/SEEPAGE PIT- OTHER. <br /> PROPERTY LINE -- PRI STIC WELL <br /> INTENDER USE TYPE OF WELL PUBLIC DONEES IC.W LL � <br /> Industrial i CONSTRUCTION SPECIFICA IQ S" , <br /> - Domestic/private ---- Cable Tool Dia, of Well Excavation <br /> i11T �' <br /> ��Drilled Dia. of Well Casing (� <br /> Domestic/public asie <br /> Irrigation Driven , s , Gauge of Casing 1 .. <br /> _ t - Gravel Pack, Dep:th�rof�Grout Ses1 _ .. <br /> Ca1-h64 c`Protection Ro.tar O .T ._ <br /> Disposal Y Type of Grout en <br /> 'Other; Other Information . slab o <br />____Geophysical -- Surface Seal Installed B vine <br /> driller .. <br /> SMP INSTALLATION: Contractor <br /> Type of Pump <br /> H..p; ` <br /> MP REPLACEMENT: / / State Work Donee <br /> NIP .REPAIR: :"" r ' <br /> / / State Woick Done <br />,:•T UCTION OF WELL: Well Diameter `, �- ,. r ^Approximate Depth .5�( �+ <br /> Je ribs �Mat r_i_ and ro6edure <br /> ' . <br /> hereby agree to comply with all laws d regulation of the' Safi­Joaquin Lo al Health istriet i <br /> I the State of California pertaining to or 'regulating well "construction. Within FIFTEEN DAYS <br /> ter completion of ,my work on a new well, I will furnish the Sani'Joaquin Local Health District a <br /> LL DRILLERS REPORT'of the well and`notify' them before°putting tl -well in use.. The above <br /> Formation is true,to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />:OR TO..GROUTING AND A FIN INSPECTION. <br /> 1NED° c�Lt. (!� TITL <br /> DRA PLOT PLAN ON REVERSE SI ) <br /> 0 PARTMENT USE ONLY ; <br /> kSE <br />?LICATION ACCEPTED BY DATE._; <br />)ITIONAL COMMENTS: <br /> .� <br /> PHA4E 11 QROUT INSPECTION PHASNA1,, INSPEI l <br /> 3PECTION BY DATE f INSPECTION BY -_Z4,DATE 4a.q <br /> I <br /> ��ace <br /> E H 1426 � Rev. 1-74 �� �IJpL� - - �- . 1/7V__ 2'M <br />