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��/, �f✓o �z nor� 7 <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -737 <br /> J6� <br /> Y74- <br /> THIS <br /> 74THIS 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 ADDRESS/LOCATION 9 7 a b F /G/Y l i p AA Aff? CENSUS TRACT <br /> Owner's Name l AG U Z�! /�/�-j Phone <br /> a <br /> Address .361f71 -3 76 0 , 1 la c /Li /✓?��- City <br /> Contractor's Name _751'j-A--7 Sv License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /7 DESTRUCTION <br /> A/fji/' PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �V1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �` d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT f / State Work Done \ <br /> PUMP . / / State Work Done <br /> DES"TRUCTION OF WELL: Well Diameter Approximate Depth <br /> D cribe Material nd Procedure <br /> / 6 6 3 - , <br /> I hereby agree to comply with all laws d 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UT G AND A FI NSPECTION. <br /> SIGNED TITLE <br /> D W POT PLAN ON RETERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASEM/FIN4& INSPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE /Q^ ��7 <br /> E H 1426 Rev. 1-74 " <br /> 3/76 2M <br />