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gF <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> E�OF-:Qifi'i.C3 USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT rf .Permit No. �S1 ( <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �.-i9 7� <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 herefln 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 Ii.eal.th District. <br /> JOB ADDRESS/LOCATION MC I<10 L�G-J Ave- , -g- Lco u t5E Ave'• CENSUS TRACT <br /> Owner's Name i N° E [_p Phone IS9-2571 <br /> 77 pp � � <br /> Address _ 'C]�X=w l{!� City ' ,o fa- <br /> i w <br /> Contractor's Name b Lehi r�gr„_o [,� . License # 240 i Phone 'S7_L. _2-75 <br /> . CJ <br /> TYPE OF WORK (Check) : NEW WELT, '/ / DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION ,/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 X� Drilled Dia. of'Wel1 Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel pack Depth of Grout Seal. <br /> Other r; Rotary Type of Grout <br /> `Other 'Other Information <br /> .t s <br /> PUMP INSTALLATION: Contractor � � u.. INC, <br /> Type of�� Pump �7,. E&P Ivy Tu2�.►.3 H.P. BOO <br /> t ri <br /> PUMP REPLACEMENT: / / State Work Done s <br /> PUMP "PAIR: � � <br /> / / §'tate Work Done <br /> ,DRgTRUCTIQN 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 4 <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 /> TELL DRILLERS REPORT of the well and notify thew before putting the well in use. The above <br /> informatia is r e to the best of my knowledge and:•belief. <br /> SIGNED ' A TITLE ALES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t (1i V <br /> APPLICATION ACCEPTEDIBY DATE - 6L 7 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE ONP III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f <br /> CALL FOR A -CROUT INSPECTION-PRIOR TO GROUTING AND FINAL. INSPE ION. <br /> -E- -H 1426 /.7-31M <br />