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F' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IFQ OFFICE USE: ii 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /3 <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 -71 <br /> e <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 ;hereia 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/LOCATIONI M/�� 'V f R*�Cro rt�_�/t A UiTi w !t'cn c� <br /> CENSUS'TRACT„ <br /> Owner's Name o�_ 9.4-6ch o s .Co / — Phone <br /> �J7 <br /> ' <br /> City Siye-10 -..�Address <br /> i <br /> ����� License #96576/ PhonecdjLy <br /> Contractor's Name / <br /> W" �d Rti���✓�► bt.f�r�r✓L.. i� <br /> ' TYPE OF WORK (Check) : 'NEW WELL / / DEEPEN/_( RECONDITION_/ / DESTRUCTION /_7AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT AZ <br /> Other <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 CCNSTRUCTLON SPECIFICATIONS <br /> Industrial Cable Tool "Dia-of Well Excavation <br /> Domestic/private, Drilled Dia, of Well Casing 4 <br /> f Domestic/public Driven Gauge of Casing <br /> �w .�--Gravel?.-P.ack... +� De -�of-Grout-seal-_ <br /> Irrigation p�th <br /> ' Cathodic Protection Rotary Type of Grout <br /> I Disposal Other Other Information <br /> I Geophysical Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> = PUMP REPLACEMENT: State Work Done�cn vin%font 25�iJ�� lTZ 3d /�� <br /> o <br /> ' e PU. I PAIR: / / State Work Done <br /> DESTRUCTION OF WELL: I Well-Diameter } Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Hea iFistr9et <br /> and the State of California pertaining to or regulating well'construction. ,,,Wi-thOnn FIFTEEN DAYS <br /> n <br /> after completion of my work on anew well, I will furnish the San JoaquiLocal Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting t6g well Win use. . The above <br /> information is true to the best of my knowledge and belief." _I�WYLL-CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION.SIGNED - ' <br /> TITLE <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> l <br /> ' PHASE Imo" DATE <br /> APPLICATION ACCEPTEDBY \1! <br /> ADDITIONAL COMMENTS:. PHASE III/FINAL INSPECTION <br /> PHASE IF ROUT INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F H 1426 Rev. - I-74 <br />