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67) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF, OF IC USS:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J3 <br /> (Complete In Triplicate) <br /> AppiicatioA 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 /> t3'bo74 *: <br /> JOB ADDRESS/LOCATIONSOri -&1 ' CENSUS TRACT /e7-`f <br /> Owner's name Farmington Land Company _ Phone <br /> Address Sonora & Henry-_goads City Farmington <br /> Contractor's Name Linden Service Pumps ,License 4E plied <br /> -Phone <br /> TYPE OF WORD (Check): NEW WELL/ / DEEPEN -/ RECONDITION / / DESTRUCTION /_7 O <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENT <br /> Other f_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> Unknown SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER } <br /> (Replaced old <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial XXX 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 /> Other Other Information ' \ <br /> PUMP INSTALLATION: Contractor rid <br /> Type of Pump --5llhM0 'sable - -- _ H.P., <br /> PUMP REPLACEMENT: -/ / State Work Done R <br /> PUMP UPAIR: l / J State Work Done <br /> ;DFsTRUCTION OF WELL: Well Diameter a 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 to the best of my knowledge and belief. <br /> SIGNED TiTLE _ Partner .-„__--- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 ' <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSIYECTTON PHAS IIJ/FIUL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE AVs <br /> ---CALI”kOk—:A-GROUT. INSPECT ON-?RIOR•TO GROUTING AND- FINAL <br /> E H 1426 .5/731M <br />