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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.J�k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,.. <br /> �3-T°� <br /> �. (Complete In Triplicate) -Z13- <br /> X 47°3Z -made to d 2 <br /> Applfeat�on is hereby made to the San Joaquin Local Hr <br /> 'Health District for 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 ��th``e Rules and Regulatio�nJs of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> lei ttt e� 14f2- Ot CENSUS TRACT <br /> GPrN�L P X <br /> Owner's Name JOE VIERRA P Phone <br /> Address 4dU"s- City <br /> Contractor's Name KENNINGS BRBS. DRILLING CO. , INC. License # 116322 Phone _ <br /> TYPE OF WORK (Check) : NEW WELL 7 DEEPEN / / RECONDITION /7 DESTRUCTION //7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / XN� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r OTHER r <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFICATIONS iV�'I <br /> Industrial ,Cable Tool Dia. of Well Excavation " 11'n <br /> X Domestic/private + Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel--Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> OtherOther Information <br /> F r <br /> PUMP INSTALLATION* Contractor Type Type of Pump �� <br /> PUMP REPLACEMENT: / / State Work Done {� <br /> PUMP_RE, AIR: // State-Work-Done �- - <br /> �1ESTRUCTION 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 /> k 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 P RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHIS II GROUT INSPECTION <br /> INSPECTION BY DATE 2-- INSPECTION BY DATE / -.23 <br /> t CALL FOR ROUT INSPECTION PRIOR TO GROUTING AND FINAL INS TION. <br /> 7/72 1M <br /> f <br /> E H 1426 <br />