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USAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> SOH OFFICE USE1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCYI-01I"CiR PUMP PERMIT Permit No. <br /> THIS• PERMIT EXPIRES 1-YEAR PROM DATE' ISSUED Date•Issued b-4-7Z <br /> j 4 (Complete-In Tfip].icite) 1S10,02_�- <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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of th$ San Joaquin Local Health?District. 11 <br /> JOB ADDRESS/LOCATION 1+001 south of Frazier Rd._ 8c 100t West_std S T C <br /> Owner's Name �_ Phone <br /> Address $ )f2 N. Clegments Rd, Liad-en City <br /> Contractor's Name PUryiance r$ e2'rj License # } Phone _1387-3551 <br /> TYPE OF`�IORK.(Check): NEW WELL '/� DEEPEN %� R;CONDIfi�ON_/_ � DESTRUCfiI N/17—` <br />' PUMP INSTALLATION / / PUMP REPAIR-/ / PUMP REPLACEMENT /7 <br /> i Other <br /> 1/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC•WELL'_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial g -- Cable Tool iia. of Well Excavation. 16 <br /> Domestic/private Drilled Dia :of Well Casing 16Tle I <br /> Domestic/public .Driven Gauge of Casing ' . _S 11r1ai-P...'1�4 � <br /> IrrigationGrave•l..Pack --Depth-of-Grbut,Seal �— 1 <br /> Cathodic Protection =oar <br /> y Type <br /> Disposal ' t Other Other Information' <br /> Geophysical.. Surf_a_ce_Seal Installed _By.-. <br /> PUMP INSTALLATION O Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT / / State Work Done <br /> PL(Mr IR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 <br /> WELL DRILLERS. REPORT of th& well and notify them before. putting the..well- in use. The above R <br /> information is true to the•best•of. my-knowledge and belief, L WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINRC±M A FINAL INSPECTION. <br /> SIGNED6,,1Z1111Iz/ TITLE rteriBT . <br /> RAW:P T­PLAN`ON RE E1tSE SINE Y• `i; ? <br /> FO <br /> PHASE I �DARTMENT USE ONLY t <br /> n <br /> APPLICATION ACCEPTED,BY• oDATE <br /> ADDITIONAL COM MTS- <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION ! <br /> INSPECTION BY DATE..t INSPECTION BY DATE i <br /> 1426 Rev. 1-74:. = 3/7 <br />