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-A SAN JOAQUIN LOCAL HEALTH DISTRICT �, S <br /> FOE OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. WX <br /> Telephone: .(209)..466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> j � M 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <br /> (Complete In Triplicate) i <br /> Application is her y 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 ttLe Rules and Regulations of the San Joaquin Local -Health District. <br /> JOB ADDRESS/LOCATION Lawrence Avenue Box 23006 Escalon CENSUS TRACT <br /> Owner's Name Otto Widman Phone <br /> �1 <br /> Address 805 CarolynCity Modesto <br /> ConfractOa'S License � <br /> Contractor's Name • • License # No.276666hone 529-2020 <br /> i <br /> -.TYPE OF-WORK (Check) : NEW WELL ,/ :-/ ..i DEEPEN / / RECONDITION /..DESTRUCTION 17 v - <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT A� <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTICl 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 iI Cable Tool Dia. of Well Excavation <br /> Domestic/private -i Drilled Dia. of Well Casing <br /> Domestic/public 4 Driven Gauge of Casing <br /> Irrigation Gravel .Pack Depth of Grout Seal ! <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal + Other Other Information'• <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done]ull jet-IIIstadl I HP Subm <br /> PUMP .REPAIR: / / State Work Done 7 <br /> DESTRUCTION OF WELL: ,. Well Diameter Approximate Deptli <br /> Describe Material and Procedure 1 <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 cell and notify them before putting the .well in use. The above <br /> information is true to the best of- my.knowledg% and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR, TO GROU.JIMG AN.4 A FIN NqPE9r <br /> 1ION. <br /> SIGNED TITLE <br /> ii(DRAW. PWT PLAN 'ON RE LRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE. III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> t I <br /> 3 <br /> E H 1426 Rev. 1-74 3/76 2M <br />