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j <br /> I/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO-6 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4) <br /> THIS 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J�3 l� l� /K) U_/ �?/� CENSUS TRACT <br /> Owner's Name ' f ' G1,2t '414 WA %Z Phone <br /> Address 5 .4 P <br /> City ,, <br /> Contractor's Name C / ✓() f(�/� ),(/ ,[� /P 'G1 License # 74 6G'.,'2—Phone 414.?-Or-3-92 <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR,/-7-pump REPLACEMENT %7 <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: e 273 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMPIREPAIR: /7 State Work Done <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 San Joaquin Local Health District a <br /> WELL D S REPORT of the well and notify them before putting.the..well in use... The above <br /> info ti s true to th best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ING CTION. <br /> SIGNED TITLE <br /> D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 0-��-e.r "I DATE -Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - =ice INSPECTION BY DATE - <br /> E H 1426 Rev. 1-74h/75 2M <br />