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t <br /> 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FAF:-OFFICE USE: 1601 E. -Hazelton Ave. , Stockton, Calif. <br /> Telephone:., (209) 466-6781 _ <br /> APPLICATION FOR ALL CONSTRUCTION OR PUMP PERMIT Permit No. <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 appi.ication 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 c{J CENSUS TRACT -- <br /> Owner's Name Phone35 - 2 5' 3 <br /> r <br /> Address - �/ GcL� / City '_ <br /> Contractor's Name 6 License # Phone41 - <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN '/? •RECONDITION /_7 DESTRUCTION f-7 <br /> PUMP INSTALLATION / / Pim REPAIR J PUMP REPLACEMENT 1_7 <br /> I <br /> Other +/ / <br /> DISTANCE TO NEAREST: SEPTIC..,TANK SEWER LINES / C' PIT PRIVY <br /> SEWAGE!•DISPOSAL/FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 PROPERTY LINE 7-" PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (�n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation I,� " <br /> F �Domestic <br /> /private Drilled Dia. of Well Casing — _ <br /> Domestic/public Driven Gauge of Casing 's <br /> Irrigation i Gravel Pack Depth of Grout Seal So <br /> Cathodic Protection i Rotary Type of Grout <br /> i Disposal I Other Other Information " <br /> j <br /> - Geophysical x Surface Seal Installed B a X/"X,% <br /> t <br /> PUMP INSTALLATION: Cont ac <br /> for <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> kDES•TRUCTION 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 /> r after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG T AND &IIN ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' - FOR DEPAUMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y. / DATE <br /> ADDITIONAL COMMENTS: <br /> INS P ION PHASE III FINAL INSPECTION <br /> INSPECTION BY - TE ;lSr=l " INSPECTION BY Z 1041- DATE -7- > <br />