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SAN JOAQUIN LOCAL HEALTH. DIST'RIC'T <br /> -POI~ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER 41 ermit No. L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is laere 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION 1=973So- n. CENSUS TRACT <br /> Owner's Name Gr1 Dag8Fman Phone $3$_7821 <br /> Address 4:9;Z36 So St _ ohn City Escalon-- <br /> Contractor's Name St g-n igj-&US pump License 1290355- Phone 522--9027 <br /> is <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN"/ / RECONDITION/_/ DESTRUCTION /7 <br /> ALYom ' <br /> PUMP INSTALLATION j—/ ­PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other .l I <br /> DISTANCE TO NEAREST: SEPTIC 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 X Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed-By:-- <br /> PUMP <br /> nstalledBv:PUMP INSTALLATION: Contractor Stanislaus Pump <br /> Type of Pump Johnston cTeep we ur ing pump R.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all'+ aws 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 well and notify them before putting the-well in use. The above <br /> information is true tothe best of my knowledge and belief. I WILL VLL FOR A GROUT INS ZCTIOW <br /> PRIOR TO GROUTING AND A F AL INSPECTION. Vi� tucui L 7 <br /> SIGNED TITLE �4 <br /> D W PLAN ON REVERSE SIDE k <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY f DATE ��'C ' <br /> ADDITIONAL OOMMMTS: <br /> PHLSE II GR INSPECTION PHA FINAL NSPECT10 <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev, 1-74 <br /> �� ; ::�� 3/76 2 ' <br /> V � <br />