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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;4141 ' 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Fpp OFFICE USE: 466-6781 - <br /> Telephone: (209) Permit No. 77. <br /> APPLICATION FOR WE CONSTRUCTION OR PUMP PERMIT 7T_-k* p <br /> _ - (e . 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 6$' <br /> (Complete In Triplicate) permit to construct <br /> in Lcal Health <br /> Application is hereby made to theSan <br /> JoaquThisoapplication istrict made inrco pliance with San Joaquin ` <br /> and/or install the work herein <br /> County <br /> Ordinance Na. 1862 and �the Rules and Regulations of the San .Toaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner'-s _Name <br /> city 41 AA C-4— <br /> Address gil� <br /> Phone <br /> License # <br /> C!l • •k <br /> Contractor's Name i <br /> - - ... 'DESTRUCTION /-7 <br /> ,*RECONDITION / / <br /> TYPE OF WORK (Check) : NEW WELL Ix DEEPEN I>p `�REPAIR % / PUMP REPLACEMENT <br /> PUMP INSTALLATION I I ^... .. - <br /> Other / _ } <br /> ' � PIT PRIVY . <br /> DISTANCE TO NEAREST: SEPTIC 1ANK �"'_-- SEWER-LINES e- OTHER-' `� <br /> GES S'POOL/'SEEPAGE PIT <br /> SEWAGE"�ISPOSAL FIELD „�__;/3, -PUBLIC DOMESTIC WELL \ <br /> i -�'""""�" PROPERTY LINE -,pR'IVATE' DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> 4 INTENDED USE ;4 TYPE OF WELL - <br /> Cable Tool Dia. of Well Excavation <br /> Industrial.- Drilled Dia. of We1lsCasin <br /> - <br /> Domestic- /private Gauge of Casing_ _LL_ <br /> Driven g --- <br /> Domestc/public; � .�- <br /> Gravel Pack Depth of Grout Seal- <br /> u Irrigation -� Rotor Type of Grout <br /> Cathodic Protection �' <br /> k � Other ¢ t Other>Information <br /> Disposal 'al Installed B G <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done Q - <br /> PUMP - -./ �S,tate'Work-....Done '"� i .w�•"`";. - ' <br /> REPAIRT 1 <br /> L Appro�?mate Depth <br /> DESTRilCTION OF WELL: Well k <br /> DescribeMaterialand Procedure <br /> to com 1 with all laws and regulations of the San 3aaquin Local Health District <br /> I hereby agree P y <br /> 4 and the State of California pertaining to a ._� 1furnish�thecSai--Joaquin. Wi <br /> LocalhHealth' Distin FIFTEEN Drict <br /> after -completon-of my-worove <br /> k on a new well;.I wi <br /> . <br /> ore <br /> WELL DRILLERS REPORT of the well and nknowledge andbelief. WILL CALL FOR,the well in us AeGROUTeINSpEGTIO <br /> information is true to the best of my �. <br /> PRIOR TO GRO ING AND INAL INP CTION. _ _ TITLE <br /> j SIGNED _ DRAWON, RE 9-kSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C°iGC� 'I _ DATE ' <br /> APPLICATION ACCEPTED BY / <br /> ADDITIONAL COMMENT PHAS III/FINAL INSPECTION <br /> F II G UT INSPECTION / <br /> k DATE INSPECTION BY DATE <br /> INSPECTION'BY _� 3I <br /> 1-14 y6 <br />