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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FAR OFFICE USS: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3s'�jv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued S AV <br /> ` (Complete In Triplicate) <br /> Application is hereby,made to thetSan Joaquin Local Health District for a permit to c6nstruct <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 19425 S. Union Road CENSUS TRACT <br /> Owner's Name' John S. .Delor-es M. Correia Phone 823-4839 <br /> Address 19425 S. Union Road City Manteca <br /> Contract is Name i ,q ` <br /> �� '�"� License /�� Phone S3�� <br /> TYPE OF WbRK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUNPINSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> -- UP �s <br /> .�..O.t,her// <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> _ - -SEWAA-GE.DISPOSAL FIELD.- CESSPOOL/SEEPAGE-PIT OTHER— <br /> INTENDED ,USE T TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial Cable Tool -fDia, of Well Excavation <br /> Domestic/private IsDrilled Dia. . of Well Casing - } <br /> Domestic/publicI <�- Driven t Gad& of Casings [ j p i , V- <br /> IrrigatfVn Gravel Pack Depth of Grout Seal <br /> Other 2 1 Rotary Type of Grout f- ! jam,. <br /> I Other ,� `- _ -�- - - _ -- <br /> _ Other Information f <br /> 1 I� <br /> PUMP INSTALLATIONS Contractor �- <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT:"`--,/ % State Work Done t <br /> PUMP REPAIR:-- -•S a 'W )-rk-Dbne <br /> �N L�fn,3,s� t y <br /> pESTRIICTION OF WELL: Well Diameter f� - Approxtimate Depth <br /> Describe Material and Procedure' :�o <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well i use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ,e.� TITLE <br /> ill DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION- ACCEPTED BY DATE 7-•J <br /> WDITIONAL COMMENTS: ;IM <br /> PHASE II GROUT INSPECTION PHASE_ III FINAL INSPECTION <br /> INSPECTION BY .;_ DATE INSPECTION BY _ DATESF^-= <br /> CALL FOR_A ,GROUT ,INSPECTION PRIOR TO GROUTINGIAND FINAL INSPECTION. <br /> E H 1426 <br /> ?/72 1M <br />