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+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 ;OFFICE USE: 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> V APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;?, <br /> _L__T5,5 [cf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> r <br /> 77 N:S�O; ? ; ;2 y� `(Complete In Triplicate) +Dol -rI v O. <br /> Application is hereby made tea 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 /> k, County Ordinance No. 1862 and the Rules and Regulations of the San Jo quin Local Health District. <br /> JOB ADDRESS/LOCATION 7- t56 }C 76 CENSUS TRACT <br /> Owner's Name 0 U/.� Phone <br /> Address JA 170 A C ,9 City <br /> Contractor's Name 19R."LL lflV GT License �E r/�Bcl Phone Y�r/BS.1.2.- <br /> . 1� <br /> TYPE OF WORK (Check): NEW WELL ,/DEEPEN / / RECONDITION / J DESTRUCTION <br /> PUMP INSTALLATION /% PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other J J - <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/� OTHER NI-) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1.--Cable Tool Dia. of Well. Excavation <br /> r/Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public 49 <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal OF <br /> Other Rotary Type of Grout ,¢g <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: J J State Work Hone <br />"UMP-`tEPAIR <br /> -w.-yam.. � --...__ � .t - �-' _�• .. 1 <br /> /=/"'State Work Done'.... <br /> DF-TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j <br />'k I hereby agree to comply with all haws 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 /> I 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 /> E SIGNED 74 D 10, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F DATE f <br /> ADDITIONAL COMMENTS: Vf <br /> PHASE TI GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE / - 2,7-23 INSPECTION BY DATE 7-2-23 <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. <br /> E H 1426 <br /> - 5/731M _ 1 <br />