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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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date_.Issued <br /> • (2 (Complete In Triplicate) <br /> Application is eby 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 Joaquifi <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> yG=tr; <br /> JOB ADDRESS/LOCATION ALLEN RD.-BEnEEN CARROLTON & VAN ALLEN CENSUS TRACT <br /> SOUTH SIDE <br /> Owner's Name ARTHUR AZEVEDO Phone 599=�_422" <br /> r. <br /> Address J20350 E. ALLEN RD. City ESCALON <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC .License # 29081 Phone x.118 <br /> 3525 PELANDALE AVE., M <br /> TYPE OF WORK (Check) : NEW WELL /X7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY " ( ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT [ER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL___,_,,,,,, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial Cable Tool Dia. of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casing 14 <br /> Domestic/public Driven Gauge of Casing 3/16 Qa <br /> X Irrigation _ Gravel Pack Depth of Grout Seal .. <br /> Cathodic Protection X Rotary Type of Grout «. <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4: <br /> PUMP :REPAIR: / / State Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter- Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON ERSE SIDE) <br /> FOR DEPARTMENTYUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION � P_H6SE,,jjIjFIWL INSPECTION <br /> INSPECTION BY DATE 'N INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br />