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�,� l®+�0 1 ro/�s . <br /> FO$�OF ICE SAN JOAQUIN L0CAL"IIEALTH DISTRICT <br /> -- <br /> USE: . <br /> 1601 E. Hazelton.Ave:,"..Stodkton, Calif. <br /> Telephone: ,,-1(209) 466;47.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. E6 <br /> THIS PERMIT EXPIRES 1-,-YEAR­FROM.DATE ISSUED Date Issued <br /> (Completela Tripl;icate), <br /> Application-is hereby made to the San Joaquin,Lvcal Health -Distract for a peT'mi.t to construct <br /> and/or install. the.work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance Noy: 1862 and the Rules and*Regulations of the San Joaquin Local health District, <br /> JOB ADDRESS/LOCAT7bN i- �S" <br /> CENSUS TRACT <br /> Owner P s Name { <br /> Phone <br /> Address:' - - - . <br /> City <br /> Contractor's Name �� <br /> License # 4! 7 i6 Phone -'%76 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/-T DEEPEN�/? RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION. PUMP REPAIR /0—PUMP REPLACEMEN-T <br /> Other _. <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS OP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC'WELL'`=--�­-PUBLIC DOMESTIC WELL SIN <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 5PECII+IC�IONS <br /> Industrial Cable Tool � Dia. of �We31 Excavation <br /> Lc Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public � Driven Gauge of Casing <br /> j. Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type' of Grout <br /> —Disposal Other �.�_ Other Information <br /> Geophysics] surface Sea <br /> . _ 1 Installed D <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> . _ H.P. <br /> NT / <br /> PUMP REPLACEME : / / State Work Done -' ~ <br /> PUMP :REPAIR: /& State Work Done J <br /> E5 TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure 'Approximate Depth <br /> I <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 anew well'. I will furnish the San Joaquin Local Health District a 1 <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. kno edge"-'"'a d belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO QRQUTING AND A FINAL I <br /> SIGNED - � <br /> LE <br /> (D W PU PLANON FRSE SIDE <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE I IN INSPECTION <br /> DATE INSPECTION BY E T I <br /> =, L/ <br /> E H 1426 Rev. 1-74 <br />