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,�,I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICES USE: /W 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-6/42 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-,;Z-2 <br /> (Complete In Triplicate) <br /> Application is herety made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This appli,:ation is made in compliance with San Joaquin <br /> County Ordinance No. :.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ J 31157 Hiway 120 CENSUS TRACT <br /> John Laugero Phone 838-2134 _ <br /> Owner's Name _ Escalon <br /> same C+.ty <br /> Address <br /> Ir Urense 529-2020 <br /> r �,::;� A;;yy7fiL� <br /> Contractor's Name License Phone_.��;_-,^.-.�_.: y <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION / i DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT F7 <br /> Other <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 SONSTRUCTION SPECIFICATIONS <br /> _ Industrial ^'2ble Tool Dia. of Well Excavation <br /> _ Domestic/private ! Drilled Dia. of Well Casing U <br /> _ Domestic/public __ Driven Gauge of Casing <br /> Irrigation _ Gravel Park Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout S <br /> Disposal _ Other _ Other Information <br /> Geophysicc.l Surface Seal Installed BY: �? <br /> PUMP INSrALLATION: Contractor <br /> Type of F'ump H.Y. \ <br /> PUMP REPLACEMENT: / / State Work Done Ra <br /> G <br /> PUMP _REPAIR: /x/ State Work Done added 10' pipe <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterTi 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 ne• well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well a^e notify them before putting the well in use. The above <br /> information is true to the best of .%y nuow dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO INE AND A JAI. INSP-S;i ION / TITLE bookkeeper <br /> SIGNED f_ L�� N i <br /> _ L_W PLOTTPLAN ON REVERSE SIDE <br /> -- FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE 'Z "�7 <br /> PPLIC <br /> ADDITIONAL COMMENTS: <br /> PHASE IZ 4ROUT INSPECTION PHAS II/ NAL INSPECTI / <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 ZM <br />