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Ar <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a <br /> FO&;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'3_/g_,7 <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 grade in compliance with San Joaquil <br /> ' ` County Ordinance No. 1662 and the. Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 16800 otter a ve anteca Ca CENSUS TRACT <br /> " Owner's Name Merle-,E. _Thompson .._ . - -- _,....._._ Phone 823 6431 . <br /> Address -10800 So CUttagg_ Ave*" <br /> city ' ' MtintPna r•a <br /> Contractor's Nance Licezise # a9D OPhone 52 D 113/ <br /> i <br /> ;- TYPE OF WORK (Check): NEW WELL.,L7 DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7-pump REPLACEMENT /7 <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " CESSPOOL/SEEPAGE PIT OTHER <br /> FROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Iridus:trialCable Tool Dia. of Well Excavation <br /> 4 Domestic/private 74/brilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Prick Depth of Grout Seal � <br /> Cathodic Protection rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed B s <br /> ..11WL <br /> 'PUMP INSTALLATION: Cotractor <br /> Type. ;of Pump H.P. <br /> b <br /> PUMP REPLACEMENT: / / State Work Done`' Awa} <br /> PUMP 'REPAIR /_ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> rI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of Cali€oruia 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 LOUXINf, AND Ap FINAL SPECTION. <br /> ' SIGNED TITLE <br /> DRAW PIAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/� DATE ?—/0J/ <br /> ADDITIONAL COMMENTS l <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> JNSPECTION BY DATE --- a f-„7I_ INSPECTION BY ATE ^�- /'77 <br /> E R 1426 Rev. 1-74 A-z4 _&4L-P, 1yed f, SO f �hh5 2M <br />