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SAA; JOAQUIN LOCAL HEALTH <br /> POR OFFICE USE; DISTRICT <br /> { 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r'3 33 <br /> THIS PERbaT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued :7--22-" <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. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local health District. <br /> Jos ADDREsS/LOCATOAt _1 _._S T.L%I.T2r <br /> CENSUS TRACT _ <br /> � Owner's Name T+Et'3Iv-kRT) 1-7.A,WI,IV Phon+P38-29 54 <br /> Address )RI <br /> 7 .'. J i <br /> City ESCALON <br /> Contractor's Name - rrtrir r-; r <br /> i <br /> License # 279010 Phone 838-2207 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /?` RECONDITION /? DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR. /X/ TIME' REPLACEMENT /-' <br /> Other /J <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TAN KS EWER LINES <br /> SEWAGE DISC OSAL` FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED-'USE i TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS ' <br /> w Cable ToolDia. of Well. Excavation <br /> Domestic/private Drilled , <br /> Domestµi.c/publ:jc - -.. Dia. of Well Casing <br /> Driven <br /> Irrigation �. • �� - •K• Gravel*Pack t Gauge of Casing <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout . <br /> Other Other Information <br /> --------------- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> _ <br /> / / State Work Done <br /> ,Lb2 '--REPAZRz-w- i I <br /> /�--State-W&rk Done -RE- MOVE <br /> ,DESTRUCTION OF WELL: Well Diameter i <br /> Approximate .Depth <br /> Describe Material and Procedure <br /> I hereby agree to cbmply with all laws and regulations of, the Sari JoaquinLocal Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS j <br /> after completion of my work on a new vell. 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 a best of my knowledge and belief'. <br /> SIGNED <br /> LE <br /> (DRAW PLOT PLAN ON REVERSETSIDE P�- M ------ <br /> 'MASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY /9. ; <br /> d'` "IONA.L COMMENTS: DATE <br /> PHASE II OUT INSPECTION P I INAL NS <br /> .NSPECTION BY if1 DATE IPEC N <br /> INSPEC DATE <br /> CALL FOR A CROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E R 1426 <br /> --___ 7/72 1M <br />