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SAN JOAQUIN.LOCAL HEALTH DISTRICT �. <br /> FOR OFFICE'USE: '` 1601 E. Hazelton Ave. , Stockton, Calif. v � <br /> Telephone:- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 5 DCy <br /> ." THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ro -`/ b <br /> (Complete In Triplicate) <br /> Application is hereby made ti. 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 .5-0- L , [J III CENSUS TRACT <br /> Owner's Namet� v G Phone <br /> Address <br /> �l y - City <br /> -- - _ j <br /> Contractor's Name <br /> 1/1/ 1� '� / License # �ZPhone <br /> -, u _ � ._ <br /> P <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT — <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of. Well Excavation 76 <br /> Domestic/private .Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing lZ - <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Other Rotary Type of Grout / <br /> Other Other Information <br /> f b� <br /> F <br /> + PUMP INSTALLATION: Contractor W� 1�3Q /' 4�- <br /> Type of Pump H.P. <br /> 1 - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> I hereby agree to compk� 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 b <br /> hem efore putting the well in user The above <br /> informatio..-44t true to the best of' my knowledge and belief. <br /> SIGNEDTITLE nom-- <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED BY �— <br /> ADDITIONAL COMMENTS: <br /> I PSE GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE dL <br /> CALL FOR A UT INSPECTION PRIOR TO GROUTING AND FINAL TNS ION. <br /> E H 1426 7/72 1M <br />