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SAN .10AQUIN LOCAL HEALTH DISTRICT <br /> r'FF1GE <br /> USE: <br /> 1601. E. Hazelton Ave. , Stockton, Calif. <br /> -� Telephone: ( <br /> APPLICATION FOR WELL CONSTRUCTION <br /> 81 OR PUMP PERMIT Permit No. ? <br />- THIS PEP-MIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-N- <br /> (Complete In Triplicate) <br />:ration is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Install the work herein described. This application is made in compliance with San Joaquin <br /> o Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dibtrict. <br /> iiil <br /> hDRI;S 5/LOCATION <br /> i-4/10 leil a P!e 3t Jack Tone & 6/10 Mile South Eitht CEAgU�TRACT <br /> is Name Dan Brandsted _ Phone <br /> ss 11090 E. bakei Road, Stockton, Cnlif. 9505 City <br /> actor's Name Furvience Dri'lers,Pox 644 3nden,Cal�f.95236License 0 240'107 Phone 931-44q , <br /> OF WORK (neck): NEW iv.r L /� D] EPEN / / RFCONDITION )r7 DESTRUCTION /7 <br /> PUMP INoTALL:.TION /I/ PUr.? REPAIR / J PUMP REPLACEInT I=T <br /> Other L7 <br /> ZI-ICE TO NEAREST: SEPTIC TANK i SEWER LINES FIT PRIVY <br /> SEWAGF DISPOSAL FIELD CESSPOOL/SEEPArm PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL <br /> INTENDED 1iSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Driven Gauge of CLaing ' <br /> Domestic/public - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout — <br /> Other Information can o <br /> Other u not. ner =I <br /> Disposal -- {M <br /> Geophysical Su--face Seal Installed BY: <br /> F <br />' INSTALLATION: Contractor Furviance Dri1lirs �7 <br /> Type cf Pumpur ne H.P. <br /> REPLACEMENT: / / State Work Done <br />" .REPAIR: / / State Work Done <br /> ERUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc-lbe :materia'_ and Procedure <br /> ereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of Cali ornia pert,'ning to or regulating well construction. Within FIFTEEN DAYS <br /> er compldtion of my work on a nev well, I will furnish the San Joaquin Local Health District a <br /> hem before putting the well in use. The above <br /> L DRILLERS REPORT of the well and notify tr <br /> 1•iowledge and belief. I WLLL CALL FOR A GROUT INSPECTION <br /> ocmation is true to the best of my <br /> JR TO GROUTING A FINAL• INSPECTIUN. <br /> !, <br />'NED <br /> TITLE ,a „ ,• <br /> DRAW 2'LnN ON RSE SID <br /> FOR DEPARTMENT USE ONLY <br />.SE i DATE ,9 / <br /> 11,1CATION ACCETTBD BY <br />"ITIONAL COMMENTS: <br /> '— .#4-j I17 <br />