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SAN JOA QUIN LOCAL HEALTH DISTRICT <br /> FOR O ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "Date Issued —L �- <br /> (Complete In Triplicate) <br /> Ipplication is hereby made to the San Joaquin Local Health District for a perinit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ) <br /> I <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone 7s7— <br /> �hmer's Name Q�4 ` // <br /> City <br /> t ddress <br /> ontractor's Name <br /> License #/� Phone 72 <br /> NEW WELL DEEPEN � <br /> DESTRUCTION <br /> PEJOF WRK c _PUMP REPLACEMENT <br /> /-7,PUMP INSTALATION /� PUMP REPAIR <br /> Other / / I PIT PRIVY <br /> TANK SE LIP5 <br /> ISTANCE TO NR <br /> _ SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial �+ -^_ Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled" Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> tOther, Other Information <br /> 'PUMP INSTALLATION, Contractor • <br /> Type of Pump <br /> PUMP REPLACEMENT: SCate Work• DDoQne <br /> 'PUMP REPAIR: / / State Work Done <br /> 'DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <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 regulatiwell <br /> thecSantJoaquin LocalWithin Health DistrAYS <br /> ict t <br /> after completion of my work on a new well, furnish <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ' information ie rue to the bes of my knowledge and belief. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI N. x/72 1M <br /> F E H 1426 C��' -u•�^p/a�� r -- <br />