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D SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFL.,•E USE: 1601 E. Hazelton Ave. , Stockton, Calif.° <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73_�,1 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <br /> ' (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 /> . C <br /> JOB ADDRESS/LOCATION 071 E_ Jones Road Escalon Calif.: CENSUS TRACT S - <br /> y Owner's Name H. & N. Development Phone gad-7066., - <br /> k Address 20001 S•.-.��_c�Iezar Escalon, Cali£. City . Escalon / <br /> I �� ��//631 A Phone 522-5643 <br /> Contractor's Name �ienn�.r:gsr 13ras„L_ License-- <br /> TYPE F WORK (Check) : NEW WELL $ J DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> 4 PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other: / / — <br /> DISTANCE TO NEAREST: SEPTIC': TANK SEWER'LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> i Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> N PUMP REPAIR: /7/ State Work Done r <br /> ESTRUCTION OF WELL: Well Diameter <br /> 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. <br /> ' SIGNED ,'6� TITLE *” ° <br /> (DRAW PLOT PLAN ON REVERSE SIDYJ <br /> FO DE ENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPT :� B DATE - 2 <br /> ADDITIONAL COMME <br /> P ROUT INSPECTION PAR INAL INSPECTION <br /> INSPECTION Y DATE — r _ INSPEC ION BY DATE7!7� <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 7/72 1M <br />