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�V1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-J11t P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> STK 10'q 6 Z:K At)'-S a .Vo.GrW Si vt 01' Icy eR <br /> JOB ADDRESS/LOCATION Q p 7- G k-7cw4F go x� CENSUS TRACT <br /> Owner's Name `�' 0 Gori Phone 3 66 - 363 1 <br /> Address 1 4 90 6F e_kA �- City _ 40,01 <br /> Contractor's Name ion cc t :a^n Penh mr C License # Phone 36' Fg71 <br /> __. <br /> L C;, :fornia 95240 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /% RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Qi <br /> Other - --- Rotary Type of Grout i + <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> �l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / ;I State Work Done loce jQiLe rueeime a 77 kijpsub <br /> PUMP REPAIR: / / State Work Done <br />,RESTRUCTION 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 <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 / + � TITLE Sacs JC- `'U"? Punzp Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY 93244 <br /> APPLICATION ACCEPTED BY DATE 12( <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIUL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />