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' SAN`JOAQUIN LOCAL HEALTH DISTRICT At PA 0 L <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. 7�r4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 3a��� <br /> � �-`� � ' (Complete In Triplicate) _ _ <br /> Application ie Hereby made to the Stn Joaquin Local 11calth 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 A?i7_e East Henry Road & 3A mile North Didds Road CENSUS TRACT <br /> Owner's Name Dr. Kistler Manch <br /> Phone <br /> Address _ <br /> City <br /> Contractor's Name Furviance Drillers P.0-Box i;j, -Linde a, G 1 i# License # 2440107 phone 931 4468 <br /> TYPE OF WORK (Check): NEW WELL El- DEEPEN ,/_7 RECONDITION [S_ <br /> 7 DESTRUCTION /_7/ <br /> PUMP INSTALLATION / PUMP REPAIR/� PUMP REPLACEMENT /f o1 <br /> Other / I <br /> __ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> ---- PROPERTY LINE - PRIVATE DOMESTIC WELL' 1 Pt3BLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRTICTIf}N'SPECIFICATIONS <br /> Domestix Cable Tool Di�, of Well Excavation ; <br /> _ c/private Drilled Dia. of Well Casing <br /> Domestic/public __._ Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal fi <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other f <br /> Geophysical —�.� . Other Information 1san 94t' sand & insta]1 1 <br /> Surface Seal Installed B li /,casing liner , <br /> P1�A.LLATION: Contractor <br /> Type of Pump <br /> - i -H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_'REPAIR: _ r /-/ .State. Work-Done <br /> LIES-TRUCTION OF WELL: Well Diameter f <br /> �i Describe Material and Procedure Approximate Depth <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. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR To GROUTING AN A F NAL INSPECTION. <br /> SIGNED- <br /> TITLE Partner <br /> - W PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY _ <br /> PIP CATION ACCEPTED BY <br /> WDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 <br />