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ov <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �y7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT re`x to. 7-7V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) f <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> PP Y 4 permit to construct I <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 /> y <br /> JOB ADDRESS/LOCATION Roy Senf <br /> CENSUS TRACT � <br /> 4321 Carpenter Rd. 463 4878 <br /> Owner's Name Phone A <br /> Address 4321 Carpenter Rd. City Stockton s <br /> Contractors Name J. A. -�halhamer Co* License # 272 303 Phone477 1858 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-T DESTRUCTION /`7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP' REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK • SEWER LINES 70 f't. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPEC T ONS <br /> .Industrial, _.._ ­-Cable-Tool- —Di-a.- o€Well:-Excavation <br /> waw +Domestic/private Drilled Dia. of Well -.Casing ,.--- `-inch <br /> Domestic/public Driven Gauge of Casing _' _.lO9 <br /> Irrigation Gravel Pack Depth of Grout Seal _�q ft. <br /> Other ** `Rotary Type of Grout Cement <br /> Other Other Information <br /> PUMP-INSTALLATION: Contractor Owner <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP REPAIR: / / 5tate._Work :Dane <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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. <br /> SIGNED TITLE <br /> (DRAW PLOT'PLAN -ON REVERSE SIDE <br /> i <br /> F FOR DEPARTMENT USE ONLY �4- <br /> A7 { <br /> PHASE I � <br /> PPLICATION ACCEPTEA,BY� _ _ DA'I� <br />"ADDITIONAL COMMENTS: <br /> P'HAU II GROUT INSPECTIONx , PHASE IIT INAL INSPECTION <br /> INSPECTION BY DATE O 3/ 3 r INSPECTION BY DATE <br /> CALL FOR A GR INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 (k+--W — + .� .,.r- v,. - r.�. w-zc1i /72 1M <br /> Illo ��/ <br />