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f <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ii (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 here:kn described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ands the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J 3115.7 Hiwa 120 CENSUS TRACT <br /> t <br /> fOwner's Name JohnLaugero Phone 838-2134 <br /> Address same t .. Escalon <br /> City <br /> :3 <br /> 5 C=,frado's License <br /> Contractor's Name ' <br /> ._,._.. � � License ,1r`� 2� 766q�p Phone 529- 020 <br /> i' <br /> TYPE-OF WORK (Check-):., }NEW- WELL:/, _ DEEPEN../_/—RECONDITION / / DESTRUCTION /-7 <br /> PUMP_ INSTALLATION / / PUMP REPAIR /x/ PUMP REPLACEMENT /7 <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 CONSTRUCTION SPECIFICATIONS . <br /> Industrial 1 Cable Tool Dia. of Well Excavation x <br /> Domestic/private J Drilled Dia, of Well Casing G <br /> Domestic/public i Driven Gauge of Casing �l <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractot <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: \ <br /> / / State Work pone <br /> PUMP-REPAIR- - /x// ---State Work Done;added-1.0-t -pi:pe <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- myknow dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 INGAND A AL INSPECTION <br /> SIGNED TITLE bookkeeper <br /> (D id p T PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ► - <br /> APPLICATION ACCEPTED BY DATE d '� <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHAS"II/t <br /> INAL INSPECTI <br />'-INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 3/76 2M <br />