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SAN JOAQUIN LOCAL HEALTH DISTRICT r i. <br /> rOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �i/ ' <br /> f. r <br /> THIS PERMIT EXPIRES l-YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tothe 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/LOCATION21 CENSUS TRACT <br /> Owner's Name _ Adam Van Ex 1 _ Phone (209 ) 369,371 <br /> Address 2 O02 K. ThoXjiton Road City L <br /> l License # 11 ine 368-4004 <br /> Contractor's Name ]� g '� ' e � Pho <br /> TYPE .OF WORK (Check) :T NEW WELL ' S/ DEEPEN '/ / RECONDITION / / DESTRUCTION /=T <br /> PUMP INSTALLATION / / 12L"MP REPAIR-/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC #TANK SEWER LINES PIT PRIVY n <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'QV <br /> INTENDED 135E TYPE OF WELL CONSTRUCTION SPECIFICATIONS % <br /> Industrial i $ Cable ToolDia. of Well Excavation 12" <br /> Domestic/private I Drilled Dia. of Well Casing tt <br /> Domestic/public I Driven Gauge of Casing 12 _ <br /> Irrigation t Gravel Pack Depth of Grout Seal 5rQ Ft. - <br /> Other -Dai== 1 Rotary Types of Grout Sand & Bement <br /> I Other Other Information �-- <br /> PUMP INSTALLATION: Contractor Domestic -Service---- <br /> Type <br /> Service-Type of Pump ,_ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> State-"Work-Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1.*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 "construc'tion. 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 The above <br /> information rue to t best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE c,2 7- 74/1 <br /> - <br /> ADDITIONAL COMMENTS: t <br /> _ .. _ PHAS -II GROUT INSPECTION- F.. PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION, BY _ r DATE - - <br /> ' CALL FOR A GROUT INSPECTIM PRIOR Td GROUTING AND FINAL INSPECTION. <br /> E H 1426 �� i <br />