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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE: USE: 1601 E. Hazelton Ave. , Stockton, Califs <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5 <br /> j� � THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED <br /> I�C 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 application is made in compliance with San Joaquin <br /> County Ordinance Na. 186ya� e Rules axed Regulations of 'the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Q <br /> 7. CENSUS TRACT <br /> i Owner's Name, 4 <br /> Address L) /,z <br /> Cit �r <br /> f Contractor's Name <br /> License # 14. 33)j Phone 6 S <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7--RECONDITION /'7 ' DESTRUCTION �- <br /> /_7 „ <br /> PUMP INSTALLATION / / PUMP REPAIR I/ PUMP REPLACEMENT f7 <br /> Other i/ / <br /> DISTANCE TO NEAREST: :SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL o4 <br /> Industrial I Cable Tool Dia, of WellCONSTExcavationECIFTCATIONS <br /> Domestic/private r Drilled <br /> Dia, of• Well Casing <br /> Domestic/public I Driven Gauge of Casing ,^ <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />.ESTRUCTION OF WELL: Well Diameter <br /> Describe Materl and Procedure Approximate Depth <br /> ia <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 /> 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 my knowledge and belief. <br /> SIGNED -`1n ., TITLE <br /> (DRAW PLOT PLAN N REVERSE SIDE) <br /> PHASE I a FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE-�� <br /> PHASE II GROUT INSPECTION PHASE III/F1NAL INSPECT O <br /> INSPECTION BY DATE INSPECTION BY <br /> t <br /> CALL FOR A GROUT- INSPECTION-.PRIOR TO .GROUTING AND ,FINAL INSPEGTION. 2 <br /> E H 1426 <br /> _ -- 7/72 1M <br />