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SAN JOAQIJIN�L&AL IiF„ LTIi DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave,. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT VPermit No. Q'4d <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued l ,] <br /> (Complete In Triplicate) <br /> Application is hereby 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 and the Rules and Regulations of the San Joaquin Local Health -District. <br /> JOB ADDRESS/LOCATION 26290 So. Union Rd. CENSUS TRACT <br /> Owner's Name Raymond Quaxesma Phone 823-1+886 <br /> Address 26290 So. Union Rd City Manteca, Cal. i <br /> Contractor's Name Hennizizs Broz..,, pril in Cg. , Inc. License # 116 Phone v5l�__ � }� <br /> 2500 W. Rumble Rd. Mo es o Ca 350 <br />_TYPE ,OF WORK (.Check) : NEW-WELL /If DEEPEN' /`/''RECONDITION -/_7 DESTRUCTION /_7_f <br /> ALi <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /? <br /> .Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC-TANK _ SEWER LINES PIT PRIVY <br /> /�'1( SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { <br /> Industrial Cable Tool Dia. of Well Excavation tt <br /> �X Domestic/private Drilled Dia. of Well Casing if <br /> Domestic/public Driven Gauge of Casing _ 1_2IGA Y � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ X Rotary Type of Grou �° ' <br /> - - Other Other Information �1�f3 - �tcrycF�Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> JDESTRUCTION OF WELL: Well Diame-te-r Appr6ximate 'Depth <br /> es <br /> `Dcr. ibe Ma a ial pd Pro edure <br /> It � — ,4 <br /> I hereby agree to comply wifh,,,all laws and regulations of. the_�Satf&JoaquinwLocal"`Health District <br /> and the State of California per"taining-t'a-ot-tegu�la ing well construction. Within FIFTEEN DAYS <br /> after completion of my work on a 1.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.n use. ' %The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTNENT USE ONLY <br />, PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: ,..r /3 /2 ..TV.S 40:: 7 <br /> PHASE II GROUT INSPECTION PHASS IIIIFINAY, INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IP CTION. <br /> E H 1426 /72 1M <br />