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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued L_Ij2272 <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 /> JOB ADDRESS/LOCATION Hwy. 88 & 12, Clements <br /> CENSUS TRACT <br /> Owner's Name Kenneth Inane Phone s <br /> Address 209-30 E. -Hw 12 City Clements - <br /> Contractor's NameLicense �� �noC}-31 Phone 7?:Z=„4R <br /> TYPE OF WORK (Check) NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /,%C� PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERi <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Cable Tool Dia. of Well Excavation <br />=! Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge -of Casing <br /> Irrigation Gravel Pack Depth of' Grout Seal I <br /> Cathodic Protection Rotary Type of-Grout i <br /> Disposal Other Qther Information n <br /> Geophysical S"u'rface -S-Oal Installed BY: f <br /> PUMP INSTALLATION: Contract of <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done \ � <br /> 4 B ar l <br /> PUMP '.REPAIR: ' State Work Done _repairs to 15_HP_Pomona <br /> DESTRUCTION OF. WELL: _ Well •Diameter -­ .Approxi-mate---Depth--- <br /> ,,:;, r+ 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 Calzfornia•.pertaining to,,or regulat�ng 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 't,e we3:l'aind Adtify tY'em f'e fore putting the well. in use. The dbove <br /> information is. ue to the best of. my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T_0 A FINAL INSPECTION. <br /> SIGNEDTITLE Secretary <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a: <br /> ADDITIONAL COMMENTS: <br /> PHASE II--GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION -BY: ; . v f ;-DATE INSPECTION BY DATE :g -77 <br /> i <br /> 1177 . _ . 2M 1 <br />