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SAN JOAQUIN LOCAL HEALTH DISTRICT a J <br /> FOE OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. . F <br /> •. Telephone: (209) 466-6781 ��,�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> S06THIS 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 f <br /> and/or .iristall 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 /> f <br /> l � <br /> JOB ADDRESS OGAT OIC.G �4-v�cd. 1`�C / CENSUS TRACT T <br /> Owner's Name - - - <br /> Phone -' <br /> y. <br />�. Address City r <br /> Contractor's Name License Phone-?6 <br /> �r�16,z3 <br /> A <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /SQ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ PIT PRIVY <br /> SEWAGE-DI-SPOSAI F1EDD "�CESSPOOI (SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool Cpia. of Well Excavation JE7 �� _ <br /> ( Domestic/privateDrilled _ . Di <br /> a. of Well Casing <br /> Domestic/public Driven z Gauge of Casing <br /> Irrigation Gravel Pack ,Depth of Grout. Seal <br /> Cathodic Protection Rotary �� . Type of Grout' <br /> Disposal Other s,,,.-Other Information <br /> Geophysical 14 ,Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - ------ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR:' /77 State Work Done <br /> a <br /> DESTRUCTION 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 on a new well, I will furnish the Saiz Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well.. an_d, notify them before putting=thewell in use.... The above <br /> information-ls--truer-to-the best-of y=knowledge�--and-belief:j WILL--•CALL-FOR-A GROUT INSPECTION <br /> PRIOR TO GR N AND A AL INSP CTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> i. FOR DEPARTMENT USE ONLY <br /> PHASE I DATE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION <br /> INSPECTION BY DATE BY �[' /� DATE_J <br /> f <br /> 2 <br /> t E 11 1426 Rev. - I-74 <br />