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f ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TL�Je <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 1, <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 /> JOB ADDRESS/LOCATION <br /> -ELL CENSUS TRACT <br /> Owner's Name LORRAINE CANTRELL <br /> Phone83-8-720.9 <br /> Address Op ELLI ROAD City EqCALO <br /> i <br /> Contractor's Name License # A20 hone <br /> 9. 3 55P 522-9027 <br /> TYPE OF WORK (Check): NEW WELL/ -/ DEEPEN/% RECONDITION /% DESTRUCTION /? <br /> t -PUMP-`INSTZLATION /—/--=PUMP -RFPA-IR-=/X/--7PW-REP-LACEMENT ;/� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED_ USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .Cable.Tool . Dia. of Well .Excavation <br /> X Domestic/Private X Drilled Dia._of,_Well Casing 6n <br /> -- Domestic/public Driven Gauge 'of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Otherllnformation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor STANISLAUS PUMP <br /> Type of Pump 1 <br /> JFT H.P. i <br /> PUMP REPLACEMENT: . <br /> State work Done <br /> PUMP .REPAIR: / State Work Done MOVED PUMP TO NEW 'WELI, ^` <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Doth <br /> I .bereby agree to comply with all laws and regulations of <br /> $ 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' .1 _ <br /> information is" true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROWING ANDA AL INSPECTION. <br /> SIGNED <br /> TITLE '�-;`:✓` <br /> D W,.p. ' pL 'ON REVERSE SIDE .,: . <br /> PHASE I <br /> :F. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE J— <br /> ADDITIONAL COMMENTS; <br /> PHASE II GR NS ECTION PHA54 III &INAL INSPECTION.- <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. l«74 <br /> ..� .. 3/76 2 . <br />