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FOR OFFICE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:., - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P <br /> ERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued d � <br /> Application is hereb (Complete In Triplicate) <br /> Y made 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 andlthe Rules and Regulations of the San Joaquin Local Health',District. r <br /> JOB ADDRESS/LOCATION 4904 E. Hildreth Lane ' <br /> CENSUS TRACT <br /> Owner's Name Ro Leale -�- <br /> Phone 931 2348 <br /> Address 490 E. Hildreth Lane <br /> City Stockton <br /> Contractor's Name <br /> License # 2 2 0 Phone A7.1 1858 <br /> TYPE OF WORK (Check) : NEW WELL DEEPENRECONDITION_ - <br /> /_/ DESTRUCTION /^7 <br /> PUMP INSTALLATION ij;/ PUMP REPAIR / / PUMP REPLACEMENT /'7 <br /> Other ' <br /> DISTANCE TO NEAREST: SEPTIC TANK 12u'ft- SEWER LINES <br /> .SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CbNSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 10 <br /> Domestic/private Drilled inch <br /> Domestic Dia. of Well Casing inch <br /> /public Driven Gauge of Casing In <br /> -- <br /> Other <br /> Gravel Pack Depth of Grout Seal 5 � - <br /> Other '� Rotary Type ft.of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor t <br /> Type of Pump <br /> . H.P. <br /> PUMP REPLACEMENT. f <br /> State Work Done i <br />?UMP�REP,AIR: State Work Done <br />)ESTRUCTION OF WELL: Well. biameter <br /> Describe Material and Procedure Approximate Depth ' l <br /> hereby agree oto- comply with all'zla ,s and regulations of the San Joaquin L-q-c :--He tth District <br /> nd the State -of California pertaining to or,.reguiating well construction. Within FIFTEEN DAYS <br /> fter completion:'of my work on a new well;. 1 ,will furnish the San•Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the wel1''And noti.'fy=them before putting the„well in use. ' The above <br /> nformation .is true to the best. of'my knowledge and belief..- v.-•" <br /> � Y F <br /> IGNED <br /> t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED By <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUTINSPECT ONP <br />�TSPECTION BY HAS I FINAL INS <br /> DATE - INSPECTION BY 1 y- DATE <br /> CALL FOR A' GROUt-INSPECTION,.PRIOR-TO-_GROUTING,AND�.- ECTION <br /> FINAL INSP .. .. <br /> E H 1426 v <br /> � I2 1M <br />