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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.7�- <br /> r. 5 <br /> THIS PERMiT'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,,g <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 15755 ESCAliON—BEI,LOTA ROAD CENSUS TRACT s' <br /> i <br /> Owner's Name NORMS STETLER Phone 523-9537 <br /> Address 22.16 De Witt City MODESTO <br /> Contractor's Name HENNING'S BROS& License #C 571 63Wone 522--5643 <br /> TYPE OF WORK (Check) : NEW WELL /K/- DEEPEN /-7 RECONDITION /-7 DESTRUCTION 7 <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 ,00 <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER 'LINES 7 PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE,-OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial " 4 Cable-Tool`* Dia. of Well Excavation //" <br /> X Domestic/private Drilled Dia. of Well Casing 6 �" <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> her Other Information <br /> PUMP INSTALLATION: Contractor L� i <br /> Type of Pump H•P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: /; / State Work Done <br /> I' ,DESTRUCTION OF WELL: '' Well Diameter Approximate Depth i <br /> Describe Material and Procedure _ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 7 <br /> and the State •of California pertaining to or regulating well construction. Within FIFTEEN DAYS, <br /> k after completion of mymwork on a new well, . I will furnish the 'San Joaquin Local Health District a <br /> i; WELL DRILLERS REPORT of the: well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO" DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP D BY DATE =- <br /> ' ADDITIONAL CO S: <br /> E O EC PUASjr I / INAL INSPECVOi <br /> INSPECTION TE — INSPE ION BY DATE <br /> CALL FOR A GROUT IN ECTION PRIOR TO GROUTING AND FINAL INSPECTION. , <br /> E H 1426 7/72 1M �'. <br />