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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: YYY 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WALL CONSTRUCTION OR PUMP PERMIT Permit No.9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�'_ /3-T3 <br /> I (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 NNo�o1862Qan4the Rules and Regulations of the San Joaquin Local Health District. <br /> oe <br /> 1 JOB �/LOCATION� a � e <br /> • /4CE� T <br /> Owner's Name Phone <br /> Address <br /> - City . <br /> e <br /> Contractor's Name License � �Phorie'� �» <br /> r TYPE OF'-WORK-'(Check)c 'NEW'WEED/ DEEP REC0NDIT 0_7'bE'STRUCTION <br /> PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other/ <br />. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES7 Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELDl - CES"SP`OOL/SEEPAGE PIT- .A-- OTHER <br /> z F W <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONSIndustrial Cable Tool Dia, of Well Excavation <br /> A:�_ Domestic/private Drilled Dia: ' of W' 11 Casing <br /> Domestic/public M Driven Gauge of Casing �- <br /> Irrigation } Gravel Pack Depth of Grout Seal <br /> Other 1 X Rotary Type of Grout <br /> f Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump L H.P. <br /> PUMP REPLACEMENT: / / State Work'Do'ne <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - f <br /> I hereby agree to comply withall lawsand regulations of the San Joaquin _Local Health District <br /> and the State of California" pertaining to o"r"fiiiilating' 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 /> WEtL `DRILLERS REPORT of the well and notifythem <br /> before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> # (DRAW,PLOT PLAN'ON REVERSE SIDE) <br /> I FOR DEPARTMENT USE ONLY t <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE 3 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASPAIIIZFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE dYj«ZJM <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPETION. <br /> E H 1426 7/72 1M <br />