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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF- I—C USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �g <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. <br /> sdandTResulationstofnis the SaneJoaquincompliance <br /> HealthSan <br /> District. <br /> County Ordinance No. 1862 and the R $ <br /> iWADDRESS/LOCATION J 18708 So. Sutliff Ave. CENSUS TRACT <br /> 7 Phone 838-23 2 <br /> Owner's Name Delfena Silva <br /> same City Escalon <br /> Address C_ r actor's L.ceriie <br /> rim r' License # No.276660Phone ' 522-2020 <br /> f'a <br /> Contractor's Name <br /> i <br /> TYPE- OF WORK (Check): NEW WELL / / DEEPEN_/ / RECONDITION /7 .DESTRUCTION /� <br /> PUMPIN9TLALATION / PUMP REPAIR f f PUMP REPLACEMENT i <br /> 0the4r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> ONS <br /> INTENDED USE STIC WELL. <br /> TYPE OF WELL d <br /> Industrial Cable Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> .Domestic/public �.-'; <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth-.of Grout- Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other 4 Other Information ' <br /> a _Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor" `-" •"". �' " -�"�' .. ... ._ _ M. -.�" �''� H.P. <br /> ,< <br /> Type of Pump .� - <br /> I'k PUMP REPLACEMENT: P / State Wo_tk'Done •lhstall 7S4C"'"'"3/4 HP- subm. <br /> PUMP .REPAIR: / / State.Woik;` one 1 <br /> -DES•TRUCTION OF WELL: Well" Diatneter- <br /> Approximate Depth <br /> Describe Material and Procedure <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 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 FINJkL I SPECTIO TITLE <br /> SIGNED Chuck <br /> �-- RA�WPL T' LAN REVERSE SIDEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: jS I I IN INSPECT N.PHASE II GROUT INSPECTION INSPECTION BDATE <br /> INSPECTION BY DATE <br /> 3/76 2m. <br /> V U IL.9A Rnv_ 1-74 <br />