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c - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> _ .APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: _3 O 3 <br /> s , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> 3 <br /> (Complete In Triplicate) <br /> Application is hereby .,ade 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-Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION HANSEN RD• BETWEEN ON SO TIN &Hedy 0 <br /> a 5 cENsus TxAcT. <br /> Owner's Name PHIL OVERHOLTZER 'CONTRACTOR Phone 529-.2664. <br /> k <br /> Address 1829 HERMIDA WAY Cit)+ MODESTO <br /> Contractor's Dame r License �� <br /> 16 .,-Phone522�, 643 <br /> + O ES O- <br />" .` • e _ _ <br /> ^fir WORK <br /> _ _ L�+f. 7�7_+_� <br />�F.cY� PEE OFWOhI.\ (Check) : NEW:...iY IYLL <br /> /X/ DEEPEN /_/ RECONDITION / / B4STRUCTION /_7 <br /> IVPUMP INSTALLATION / / P r'I1P REPAIR PUMP REPLACEMENT /7 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Lao SEWER LINES PIT PR <br /> SEWAGE DISPOSAL FIELD CESS OL/SEEPAGE 'PIT� OTHER t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excava.ta 11r► <br /> Domestic/private ' � Drilled Dia. of We11. s g i it <br /> Domestic/public Driven Gauge of <br /> rp Irrigation Gravel Pack Depth�of Goun <br /> Seal t <br /> Other Rotary Tof Grout <br /> e ----� � ~ <br /> -- _ Yp <br /> Other ,,Other Information . 23 n by C&npr_ <br /> r" <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump / <br /> .H.P. ' <br /> PUMP REPLACEICNT: / / State Work Done G� <br />—PUMP=kEPA1Rq YY �- /�:/~ "S tate .- <br /> "fi�ork one� D�-_...`_L� - <br /> ,DFgTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material an Procedure <br /> I hereby agree to comply with all laws and. regui' Cions of the San Joa. uirt oca Health District <br /> and the State of California pertaining to or regula -ug we1]�su 'ion. ' 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 wellin use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED l <br /> PLOT PLAN ON REVERSE SIDE <br /> FO <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL C0110JENTS: ---- <br /> PHASE 11 GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -DATE <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 f <br />