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SAN JOAQUIN �,OGAL 4iEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> 3 2_ 7�1�1) <br /> -ap i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB MWMW/LOCATIONze �'o Z , r <br /> ,1 AZ1140, <br /> _CENSUS TRACT D87- �?o 3Z <br /> Owner's Namet.1Phone <br /> AddressCPUCity <br /> Contractor's Name4174-7,1 l <br /> �.� ,Aw, �' „e�,1�,7,� License ALM Phone /7 7/ %/ <br /> I <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 4 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESQ PIT PRIVY <br /> SEWAGE DISP SAL FIELD 4Q&p ML/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 <br /> /public Driven Gauge of Casing /Z d� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other x Rotary Type of Grout .c--' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ? ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done + <br /> PUMP REPAIR: 17 State Work Done <br />,LESTRU_CTION 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 ona 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 /> =i <br /> SIGNED TITLE <br /> �- (DRAWPLOT PLAN ON REVERSE S ID���� .,...__ <br /> F R DEPARTMENT USE ONLY <br /> PHASE I BY 1� <br /> APPLICATION ACCEPTED cJ ATE � �� � <br /> ADDITIONAL COMMENT <br /> P G INSPECTION PHAS .� �ajLINSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE F <br /> CALL FOR A D ,TION PRIOR TO GROUTING AND FINAL INSP N. <br /> E x 1426 J 7/72 1M <br />