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FOHaOF I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ � USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Gt,S <br /> APPLICATION FOR WAL CONSTRUCTION OR PUMP PERMIT Permit No. �0 _�� <br /> --------------------- <br /> THIS PERMIT EXPIRES I. YEAR-FROM DATE ISSUED Date Issued 1-,-?j-71 <br /> (Complete In.Triplicate) �--- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance.No. .1$62 and the Rules.and Regulations of the :San Joaquin Local -Health District. <br /> JOB ADDRESS/LOCATION, .1'1 <br /> �A CENSUS TRACT- <br /> Owner's Name <br /> r Phone <br /> Address <br /> ` City <br /> Contractor's Name <br /> License # AiT-;02,� Phone Y- .7-` <br /> TYPE OF WORK (Check) : NEW WELL <br /> /? DEEPEN / J RECONDITION /_7DESTRUCTION /_7 <br /> PUMP INSTALLATION /K/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other t <br /> 1 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTYILINE PRIVATE DOMESTIC WELL PUBLIC DOMESTI.CQ WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> i <br /> DomesticJprivate Cable Tool Dia. of Well Excavation <br /> _Lc '� <br /> Domestic Dia. of Well Casing <br /> /public ;t Drilled Driven Gauge of Casing <br /> Irrigation �! Gravel Pack Depth• of Grout Seal F <br /> Cathodic Protection #i Rotary T <br /> Disposal YPe of Grout <br /> F� Other, Other Information E <br /> Geophysical � - Surface Seal Installed B <br /> PUMP INSTALLATION: '' ` T <br /> }�Con-tractat •-y4 - <br /> Type of l EPump <br /> ?UMP REPLACEMENT: <br /> State Work_ Done , <br /> 'UMPpIt: <br /> 4/ State.Werk�Done L / <br /> ES•TRUCTION_ OF WELL: Well Diaineter <br /> Describe .Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the an Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> €ter completion of my'work on'a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting-thewell in use.,. The above <br /> nformation'is true to the bestiof my k. wle nd belief. I WILL CALL FOR A GRO <br /> 3IOR TOG UTING ANDA FINA INSP IO UT <br /> TGNED INSPECTiON <br /> TITLE ' �f <br /> RA14 PL T LAN ON VERSE SIDE) <br /> MASE I FOR DEPARTMENT -USE ONLY <br /> PP' ' ,TION ACCEPTED BY <br /> 16. <br /> )D JNAL COMMENTS: DATE Z_ q d`7 <br /> PHASE II GROUT INSPECTION <br /> dSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE ,,S "7,1 <br /> E H 1426, Rev. -I-74 b;17 Stu " <br />