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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0'E OFIICE, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 0 -' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-7 -,//Fzi/ <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ��j - 75- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constl:uct <br /> and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance No. 7. 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> —, <br /> Owner's Name <br /> JOB ADDRESS/LOCATION 1,�,fa g6 4US TRACT <br /> Phone <br /> (3a, r b7 a 2�u <br /> Address Cit <br /> !L,?�/ <br /> Contractor's me License # Phone, - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PURI' REPAIR PUMP REPLACEMENT-- /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN: 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 7M <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing; z* <br /> Irrigatr'Qn Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information <br /> PU'Q INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> State Work Done <br /> U114P '�,LPAIR: <br /> DFqTRUCTION OF WELL: Well Diameter 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 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, o the best of my knowledge and belief. <br /> SIGNED i)Aj/�jtt& TITLE <br /> 'V '(D W PLOT' PAN ON REVERSE SIDE) <br /> J04 DEPARTMENT USE ONLY <br /> Pi;ASE I <br /> AP?L1Ci'1),TID ON ACCEPT DATE <br /> ADDITIONAL COHI�4,ws <br /> - <br /> WSE /f T,//OROUT INSPE­C'fI0N' P4SR/'IIt41,ftNAL INSPECTION <br /> INSPECTIODATE INSPECTION <br /> DATE <br /> CALL 1-'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E K 1426 5/731M <br />