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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICIO USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> T Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y <br /> 76 -�a ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2_-2a_-24 <br /> -'4 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or iastall the work herein described. * This application is made in compliance with San Joaquin <br /> County Ordinance�lo. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .FOE ADDRESS/LOCATION �,0 CENSUS TRACT <br /> f r <br /> Owner's Name _ Q 1 Phone <br /> Address — /'-2_S-V/ - 7u44 <br /> Contractor's Name' i_z g.,zei(z�4q4towAt ±064000License #_?SO/4 3 Phone 8417- 90 s7�ff <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_7 RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION _IN PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 9,9 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 40 <br /> _ Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven _ - �.. Gauge of Casing. - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other — Rotary Type of Grout <br /> 4 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> .�7-'6 <br /> Type of Pump H.P. >% .. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED /1.�y� 1�►r� !� TITLE <br /> (D PLOT AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED-•8X . .' !it �! DATE <br /> ADDITIONAL COL011ENTS: <br /> PHASE II GROUT INSPECTION 1' PHASE III/FINAL INSPECTION <br /> INSPECTION BY e-o DATE �i2`�� INSPECTION BY � :�f . DATE f-1-1 <br /> ­CALL­F©R A.GROUT INSPECTION, PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ 5/731M <br />