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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;•OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - ,xQ09) 466--678I <br /> APPLICATION FOR VEL'L�CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date Issued LL_.7_o-2(_' <br /> (Complete 'In Triplicate) <br />-Application is' hereby made to'jthe 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 o. 1862 and the Rules andRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA Io n lr soj. P t ENSUS TRACT <br /> j <br /> Owner's Name Phone <br /> Address, City <br /> License # Phone A <br /> Contractor's Name License <br /> TYPE OF`,WORK (Check) : NEW WELL /DEEPEN /� RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / I PUMP REPAIR'/? PUMP- REPLACEMENT <br /> _ Other <br /> DISTANCE TO-NEAREST: SEPTIC TANK-.- <br /> ANK-. " SEWER LINES FIT PRIVY <br /> SEWAGE DISPDSAL`FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> V PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _= ' Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation V Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical. - Surface Seal Installed B : <br /> k PUMP INSTALLATION:I Contractor /4L.� v+� <br /> K Type .of Pump H.P. .. . ' <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP ,.REFAIR: . ` / / State Work Done <br /> DESTRUCTION OF WELL: Well'biatteater4Approximate Depth <br /> Describe Material and Procedure _ <br /> I here agree to complyCwith all laws and regulations of the San Joaquin Local Health District <br /> and the` Sta lifoxnia' -.0ertain t or regulating well"construction. Within FIFTEEN,DAYS' <br /> after cc etion •of y work 'on..a: we will furnish the San Joaquin Local Health District a <br /> WELL DRI ERS PORT of the well n' if theta before putting..the..well in.use.., .The above .� <br /> informa. on is rue t •-Ithd, yes -kn edge a LL CALL F UT IN <br /> PRIOR GR A � <br /> ;SIGNED TITLE4:�114_�/V9 <br /> k i _ DRAW_FLOT-­PLAN-ON."REVERS <br /> f= FOR,,DEPARTEMT USE ONLYa� <br /> . PHASE I J <br /> ``APPLICATION ACCEPTED BY ► <.� , ,�. + DATE <br /> ADDITIONAL COMMENTS: ► " ,. .` �'' ' ' ' - <br /> PHASE II GROUT INSPECTION ' PHASE' III=FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> V A ILIA 9 t7— I._7A <br />