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r1601 <br /> SAN JO��QUIN�LOCAL"HEALTH DISTINCTFOA,0FFICE USE: E. Hazelton^Ave. ,.Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES--1YEAR FROM DATE ISSUED Date Issued /0--7-75- <br /> 3 w (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;.,:.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/L ATION S. Jacktone CENSUS TRACT . .�. <br /> Owner's Name Cliff Eskes Phone <br /> Address— =- "224 West Third"Sty i-'Rlporn,Y Calif."- - - City <br /> R f <br /> Contractor's Name N & S HOME APFLIANCE CO. License J199612 Phone 599-3456 <br /> TYPE OF WORK (Check_ ): NEW WELL // DEEPEN '/? RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT % J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N ; <br /> PROPERTY-LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL z CONSTRUCTION SPECIFICATIONS <br /> ' .Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private t Drilled Dia. of Well Casing: <br /> Domestic/public 1 Driven . Gauge of Casing <br /> 'Irrigation Gravel'Pack Depth of Grout Seal <br /> Cathodic Protection Ri Rotary $ Type of Grout <br /> Disposal: :ii Other Other Information \ <br /> Geophysical Surface Seal Installed BY: <br /> } ti <br /> PUMP INSTALLATION: Contractor N & S HOZ APPLIANCE 00. <br /> Type of Pump Submersible H.P. <br /> PUMP REPLACEMENT: / / State Work Done R <br /> S tateWork'Dane _ <br /> ,QES.TRUCTION OF: WELL: Well Diameter Approximate Depth <br /> Describe Material andiProcedure <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 orfregulat.iug 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..we11 in use.. ' The above <br /> information is true to the-bet of my knowledge and belief. 'I WILL CALL FOR A- GROUT INSPECTION <br /> PRIOR TO M9=Uif,4ND A/AINAL INSPECTION. +` <br /> SIGNED �..t - TITLE Partner ° 1 <br /> DRAW PLOT PLAN ON-REVERSE SIPT77 s <br /> FOR DEPARTMENT USE�;ONLY <br /> PHASE I t. <br /> APPLICATION ACCEPTED-BY � "°' """ "-"`�"" """""" DATE 5-_2 -y- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III NSPECTI92 <br /> INSPECTION BY DATE °`tNSPECTION, BY DATE - <br /> 1 E HR 1426„ - Rev. 1-74c'�L�^ G r.��i fug r <br /> �� / '-- 1-74 2M �" � <br />