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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: r 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: %(209) 466-6781 <br /> APPLICATION FOR-�WhI>CONSTR. CTION OR PUMP PERMIT Permit No. ,Il <br /> THIS PERMIT EXPIRES ,1 YEAR FROM DATE ISSUED Date Issued l <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 /> JOB ADDRESS/LOCATION tQ Z_ CENSUS TRACT <br /> Owner's Name !/CJ ' = 'r *11e,t- Phone <br /> Address: Q <br /> City <br /> Contractor's Name ID4t License 4�/ oZ3 honed <br /> 'Y{ <br /> �-T-Y-PETOF WORKS(Check)-:- --NEW­WEL-L- /7.DEEPEN RECONDITION -/_7�7- �DESTRUCTION <br /> PUMP QINSTALLATION /W PUMP REPAIR / / PUMP REPLACEMENT <br /> �. - <br /> � .. 4-- <br /> DISTANCE TO NEAREST: SEPTIC%TANK a . _.- SEWER JLINES _ ^ PIT PRIVY <br /> %} /SEWME'DISPOSAI FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPiRTY LINE--t-1 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> .r <br /> INTENDED U5E1TYPE ,OF.WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial �._ J. Cable Tool Dia. of Well Excavation <br /> Domestic/privates, tr) -t Drilled Dia, of Well Casing. <br /> Domestic/public �� _ Driven Gauge of Casing <br /> Irrigation ° Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 ► Rotary Type of Grout <br /> Disposal I OE er Other Information <br /> Geophysical s Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto"r. <br /> ype of Pump' Zi4LP__cH.P. <br /> PUMP REPLACEMENT: State Work Done �� <br /> { , <br /> PUMP .REPAIR: t - /% State_Work Done . <br /> • 'S qM1 'eT�+—t-"y—.-�iw 3~).. -.. ,„l.bsw+hr..w+• <br /> kDESTRUGTiONTOF-WELL: Well~ Diameter Approximate'Degth <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 ttW State of California� pertainirig to or regulating well 'construction. Within# FIFTEEN DAYS <br /> after, comple n_of my work'. on a new well, I will furnish the San Joaquin Local Hgalth District a <br /> WELL DRILA' S REPORT o t well ands ti before putting. the .well in use. The above <br /> `iriforinat n wis :tr. egt _.t best f m ' ed and e . I WILL CALL FOR.A-GROUT INSPECTION <br /> :`PRIOR TO ROUT A INAL <br /> SIGNED-) TITLE <br /> _(DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE7v , <br /> ADDITIONAL COMMENTS.:. <br /> '^PHASE' I GROUT INSPECTION' PHAS FINAL I SPECTIONI� <br /> INSPECTION BY DATE INSPECTION BY DATE 11 <br /> E H 1426 Rev. 1-74 214 <br />