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� }} .1H <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT 44-2,. � <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. i <br /> Telephone: _(209) 466-6181 j <br /> APPLICATION FOR ALL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3S3 il/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7- 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 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 ! �' / CENSUS TRACT <br /> JL �1 �roX. rr1j. . b� F SidP.. 3TM <br /> Owner's Name a 1�-' ,, ----- A Phone lP Q� <br /> Address - .__�11d_t) eea. . , City .. W n4e 6_-_ <br /> Contractor's Name _14eni ,�(�j-�/_ ra �Tnc, License # 9G' !3 Phone 5�aQ=Ie / <br /> i <br /> TYPE OF- WORK (Check) : -NEW WELL DEEPEN / / RECONDITION' /_7 -DESTRUCTION /7 t '- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,{{ SEWER LINES /UQN� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �/4►U€ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC TIC 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 - Vy qcL, <br /> Irrigation ,� Gravel Pack Depth of Grout Sea]. n tT <br /> Cathodic Protection }Rotary Type of Grout _ k?etAP } <br /> Disposal Other , Other Information <br /> Geophysical Surface Seal Installed^By:_'_ t1all .^ <br /> PUMP INSTALLATION: Contractor- z % <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: / / State ,Work Done 1 ;` <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> u 1 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local-Health District i <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 <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. # <br /> SIGNED ' __ <br /> TITLE _ <br /> ­fDRAW PLOT PLAN ONvREVERSE SIDE) <br /> FOR DFMTHENg USE ONLY <br /> PHASE I _ "" <br /> APPLICATION ACCEPTED BY �� DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION P S I/FINAL INSPECTION <br /> INSPECTION BY ,/ ]_ DATE INSPECTION BY DATE 7� -7-7 <br />