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SAN JOAQUIN LOCAL .I ) ALTH DISTRICT <br /> FOR OFFICE USE: 1601 L. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: . (20,9) 466-6781 <br /> AIAPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> • a <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED , Date Issued <br /> j; <br /> (Complete .In Triplicate) i <br /> Application is hereby made to' the San Joaquin Local, Health District for a permit to construct <br /> and/or install the=Wolrk 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. ii <br /> JOB ADDRESS/LOCATION �OG/'�/'� 4' ,�(? ��f,�� s/+ CENSUS TRACT ; <br /> Owner's Name ANDY ALFIERI Phone 838-2396 { <br /> Address ' 206. !E. HIWAY 120 ESCALON CALIF. City <br /> HENNINGS �BROS. DRILLING CO. INC. License #116322 Phone 522-5643 r, <br /> Contractor's Name ? Qq� <br /> TYPE OF WORK (Check) : N�W WELL �x DEEPEN / / REGONAITIQN DESTRUCTIOI3'/�v <br /> PUMP INSTALLATION / / PUMP REPAIR/ / Pump REPLACEMENT <br /> E Other l/ / 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT`PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ! OTHER <br /> INTENDED USE ; TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private � , Drilled Dia, of Well Casing 1 �� <br /> Domestic/public Driven Gauge of Casing <br /> } i X Irrigation Gravel Pack Depth of Grout Seal . <br /> Other Rotary Type of Grout <br /> _ Other Other Information <br /> 1 � <br /> k PUMP INSTALLATION: Contractor <br /> 'l Type of Pump H.P. <br /> IT <br /> i PUMP REPLACEMENT: / '/ State Work,Done <br /> PUMP REPAIR: State Work Done <br /> r '. ESTRUCTION OF.WELL: We`11 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 � <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 /> s information is true to the best of my knowledge and belief. _ <br /> !" SIGNED TITLE 0 <br /> ( <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY - _ ___ _ -_, ___..._ . _--_--_- -..--DATE -/�-�2� <br /> ADDITIONAL COMMENTS: a <br /> } PHASF II GROUT INSPECTION PHAS II FINAL INSPECTION <br /> INSPECTION BY� '� DATE INSPECTION BY DATE �- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL"' INSPECTION. <br /> E:B 1426 4/72. 1M <br /> r.. <br />