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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �p T TS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued In/2:7-77 <br /> ' (Complete In Triplicate.) <br /> Application is hereE'y ade to the San 7aaquin 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 /> f4 w y <br /> JOB ADDRESS/LOCATION 25588 E. Miller Pod, Escalon, Calif. CENSUS TRACT <br /> Owner's Name Raymond H. Cadlolo Phone 838--2780- <br /> Address 2. 88 B. Miller Rd. ;;scaZon, Calif. City Becalon, Calif. <br /> Contractor's Name ^ewn License # Phone 838-2780 <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN RECONDITION /_/ DESTRUCTION /- <br /> AL _ <br /> PUMP INSTALLATION / / -PUMP REPAIR / / PUMP REPLACEMENT <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 T— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q! <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor own <br /> Type of Pump submersible H.P. one .+.' <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP .REPAIR: / J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 GROU ION. <br /> SIGNED TITLE mer l� <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 2j DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION V PHASPI)IA I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A/ ,1• NtAM,-DATE <br /> s E H 1426 Rev. � 1-74 <br /> 0!77 . <br />