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JOAQUIN _•LOCAL HEALTH DISTRIC <br /> FOP,'OFFICE USE: 16{,_-E. Hazelton Ave. , Stockton, Ca:L.-. �v <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 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health..District. <br /> JOB ADDRESS/LOCATION 201 50 So • Van Allen Escalo.n CENSUS :TRACT <br /> Owner's Name Clarence Din Dulk Phone <br /> Cit Carlisle.,: Penn.. . <br /> Address R D.-I . y <br /> Contractor's Name <br /> He Bros . Drilling Coo , Inc.' ` License U z90$13 Phone 522.1031 <br /> TYPE OF WORK (Check): NEW. WELL FV DEEPEN /_T RECONDITION /7 DESTRUCTION -/_? <br /> PUMP INSTALLATION"/ / PUMP AFFAIR'/� PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OldWell <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER 10c) <br /> PROPERTY LINE - PRIVATE DOMESTIC-WELL:-- PUBLIC DOMESTIC WELL fl <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well- Excavation lin <br /> XX Domestic/private Drilled Dia. of Well Casing T' <br /> Domestic/public - Driven Gauge of Casing 12 Ga <br /> Irx-igat�ion rave ;Pack=--depth of-Grout�eal <br /> Cathodic Protection Rotary Type of Grout BeAjOnite <br /> Disposal Other Other Information"_- Slab by owner _ <br /> Geophysical ,Surface SeaL Installed '8, i D filler <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT i . . El State Work Done <br /> ,PUMP "REPAIR: /7 State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate DepthW <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"constructiou. 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 q4L.FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ) f, ECTIYMBK. <br /> SIGNED. 5 DRILLING CO. INC.. TITLE. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTId PHASE TII FINAL INSPECTION <br /> INSPECTION BY DATE .S`r 7� 'INSPECTION BY DATE <br />