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SAN JOAQUIN LOCAL HEALTH DISTRICT ? i <br /> FOArOFFICE USE; '` -' 1601"E. `Haxelton Ave. , Stockton, .Calif. <br /> Telephgne: (209) 466-6781 <br /> APPLICATION FOR',W= CONSTRUCTION OR PUMP PERMIT Permit No. 7 f 2Sy4.jr <br /> k <br /> M7q- <br /> THIS PERMIT EXPIRES 1 YAR FROM DATE ISSUED Date Issued - T�} <br /> I (Complete In'Triplicate) <br /> Application is hereby made to the Sati 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 /> JOB ADDRESS/LOCATION r �.C3dt.jC's L CENSUS TRACT <br /> Owner's Name ,C- / PhongM,,, <br /> Address City 1 <br /> Contractor's Name " • °' -ar License #9- VP�Fel Phone 92 e,;'" 143i <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION PUMP REPAIR /� .PUMP REPLACEMENT f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO YIELD CESSPOOL/SEEPAGE PIT MC101OTHER <br /> 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 Drilled Dia. of Well Casing <br /> -- Domestic/public Driven Gauge of Casing` <br /> e" Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j!j_ State Work Done <br /> PUMP .REPAIR: L7 State Work Done <br /> ,RE5TRUCTION 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 REPORTel) the well and notify thew before putting the. well use.. The above <br /> information is tr d to the-best.o£ my knowledge and belief. I WILL RA 'GROUT�INSPECTION <br />_ PRIOR TO <br /> SIGNED TIT <br /> -�, — --- DRAW-PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/�-�,�, <br /> APPLICATION ACCEPTED BY ,CJ o/ c DATE E-I7-7c' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1`i E H 1426 Rev. 1-74. 1-74 2M <br />