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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J�- aa7�J <br /> t <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issued r�_>_.f <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION 15755 ESCAI,ON—BELLOTA ROAD CENSUS TRACT s- <br /> wner's Name NOR14A. STETLER Phone 523-9537 <br /> .ddress 22.16 De Witt City MODESTO <br /> ontractor's Name HENNING'S BROS e, License #0 5711634one 52.2-5643 <br /> YPE OF WORK (Check) : NEW WELL /S7 DEEPEN /7 RECONDITION DESTRUCTION`%� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> iISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES 7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE•OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable=Tool, Dia, of Well Excavation // <br /> XDomestic/private Drilled ` Dia. of Well Casing 6 i" <br /> Domestic/public Driven Gauge of Casing /17 CP <br /> Irrigation Gravel Pack Depth of Grout Seal J:j! ' <br /> Other X Rotary Type of Grout ,Q­"A, <br /> her Other Information <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: /` /' 'State Work Done - ---- "--- T- 1 - _ <br /> )ESTRUCTION OF WELL: ,' Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS. <br /> i€ter completion of my-'work on a new well, . I will furnish the 'San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the. well and notify them before putting the well in use. The above <br /> Cnformation is true to the best of my knowledge and belief. <br /> SIGNED �{,!'�� - TITLE <br /> ,l (DRAW PLOT PLAN ON REVERSE SIDE^e!A <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE - 'ti—. '3 <br /> APPLICATION ACCEP D BY ' �-JZ7 <br /> ADDITIONAL CO S: <br /> E V1 KA0 E PU&Sjr I / NAL INSPE O <br /> INSPECTION TE — INSPE ION BY DATE <br /> CALL FOR A GROUT IN ECTION PRIOR TO GROUTING AND FINAL INSPECTION. Ci <br /> E H 1426 7/72 1M �' <br />