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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOF;�OFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone : (209) 466-67817 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 97 <br /> (Complete In Triplicate) <br /> Application is hereb 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 /> ` S_ i CENSUS TRACT <br /> JOB ADDRESS/LOCATION 9249 S. Sexton Rd. Escalon <br /> Owner's Name Hazel F. Pope Phone 838-2994 <br /> Address 19249 S. Sexton Rd City Escalon <br /> I <br /> � <br /> Contractor's Name License � S Phone 8il� �'� <br /> a <br /> TYPE OF WORK (Check) : NEW WELL W1 DEEPEN / / RECONDITION �/ DESTRUCTION /7 _ <br /> PUMF. REPLACEMENT <br /> PUMP INSTLATION PUMF REPAIR <br /> AL / <br /> y Other <br /> DISTANCE TO NEAREST; SEPTIC TANK moo Fr SEWER LINES lS Fr PIT PRIVY —dp' <br /> SEWAGE DISPOSAL FIELD ,SOS FrCESSPOOL/SEEPAGE PIT _,9- OTHER _ <br /> PROPERTY LINE/Z�PRIVATE DOMESTIC WELL ld-Ar PUBLIC DOMESTIC WELL -=� <br /> CONSTRUCTION SPECIFICATIONS <br /> ti INTENDED USE TYPE OF WELL �4 <br /> Industrial Cable Tool Dia. of Well Excavation -\h <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X' Gravel Pack Depth of Grout Seal T <br /> Cathodic Protection Ae Rotary Type of Grout e,✓ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B 114": <br /> t <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ' <br /> �r1 <br /> DESTRUCTION OF WELL: Well Diameter A pr ximate D th <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationsA <br /> 3oaquin Local Health District <br /> and the State of California pertaining to or regulatintruction. 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. r <br /> SIGNED _ y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> e G L OR j PARTME T USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED 1 C <br /> ADDITIONAL COMMENT :\( ^f"�4 <br /> PHASE?fI ", —INSPECT ON / PHA E II AL IN FECTI N <br /> INSPECTION B ,$�' a DAA q /Zr1 / �_ INSPECTION BY DATE 7 <br /> f � r <br /> �, 17 _ <br />