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b SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> FOR OFFICE USE: 160.1 E. Hazel torn-�Ave.',�--Stock toot, Calif. <br /> I ; V' Telephone: -: (20:9)4.:�b6�6783. 7A <br /> APPLICATION FOR WELL GONSTRUCTIDN,,:OR PUMP PERMIT Permit No. 7A <br /> THIS PERMIT'-'KXPIRES-•12 YE+ARIF'ROM- DATE-'ISSUED -Date .Is'sue'd <br /> tln, Trrp-llcate) i <br /> Applicat�oin'"is5hereby,,.ma,de'.E.to !t'he;},SaaizJ,'oaqu, n,L�Gal �Realth District• for a permit to construct <br /> and/or install the work herein described. Thigt,,Tapplioat Son' is` made in- compliance.. vith% SatilJoaquin <br /> County_�,Qrd nanrce�No.,i l'862=^gar►dN the� i,le's':and"----Re•gulati•o'ns r of -the.. San Joaquin Local-,Health- District.- <br /> JOB <br /> ocal Health- District:JOB ADDRESS/LOCATION J17076 -South Sieidner, Escalon CENSUS .TRACT ` <br /> a irad3'Sf �1i A3.�C � )S W1e3 `i'x3"fi f ?913 f`S7 <br /> yy <br /> ..l <br /> N Phone 838-72 <br /> Own er':s ' ame::_ r,Jsd �solk ", 6Y` <br /> Address sameas above Cit Escalon _ <br /> Contractor's !Name I.J. Larsen. Pumps, Inc. _ License # 276660 Phone 529`2020 <br /> TYPE OF WORK (Check) : NEW WELL '/�/ DEEPEN / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION ;K / . PUMP REPAIR /^/ . PUMP REPLACEMENT / <br /> :....._ <br /> DISTANCE TO NEAREST: SEPTIC'-TANK, SEWER LINES PIT PRIVY , <br /> ;SEWAGE DI'SPOSAL. FI.ELD,. -- CESSPOOL/SEEPAGE PIT.. OTHER <br /> -INTENDED"USE. -TYPE OF WELL <br /> 'CONSTRUCTION SPECIFICATIONS <br /> Industrial .. Cable Tool Dia. :of Well Excavation <br /> Domestic/private; x Drilled pia. of Well Casing j <br />`. Domesti:c/piublic Drl.ven Gauge of Casing p <br /> Irrigation. Gravel Pack Depth of Grout Seal <br />'s Other kotary Type 'of Grout <br /> Other Other. Information <br /> PUMP INSTALLATION: `' Contractor <br /> Type of Pump H.P. a <br /> i PUMP REPLACEMENT: I / 'State' Work Done ; <br /> PUMP REPAIR: / State Work Done <br /> Approximate Depth -36^� <br /> DESTRUCTION OF WELL:.. Well Diameter pp <br /> i <br /> Describe Material and Procedure <br /> I hereby agree to comply with- all laws and regulations of the San Joaquin Local Health District <br /> andithe State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of' m* y. work on a new well, I will furnish the San Joaquin Local Health District a <br /> t WELL DRILLERS FEP RT of the we 1 and notify them before putting the well in use. The above. 3 <br /> information iso trde' a e bes ' of' y-3- g ledge and belief. s <br /> SIGNED. <br /> TITLE: .President <br /> (DRAW PLOT 'PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE -ONLY <br /> PHASE I r <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS,: <br /> P I OUT INSPEC NPHA / NAL INSPECTION �� <br /> INSPECTION BY c. DATE INSPECTION BY V DATE <br /> CALL k'n26R.A GROUT INSPECTION�PRIOR.TO GROUTING..AND FINAL INSPECTION.. . <br /> E H 14 - 4/72 IM <br />