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a <br /> .1,ws SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '. Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7j-,•�--�>611 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5--30-25 <br /> (Complete In Triplicate) -/Y" <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 47— wlc- 014 �lV CENSUS TRACT <br /> Owner's Name/M, a- n P <br /> Phone .x '7/� <br /> Address ( ': ,/ "4 CitS�VC&Z]2^/ <br /> y��. <br /> Contractor's Name S t <br /> License a ct Phone <br /> �y-51 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEP.EN"/7/ RECONDITION /_/ DESTRUCTION /7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V�' <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 /> 4--- �omestic/private Drilled Dia, of Well Casing Y <br /> Domestic/public Driven Gauge of Casing <br /> __I_,--'Irrigation Gravel Pack Depth of Grout Seal <br /> ii <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Sal Installed_By: <br /> PUMP INSTALLATION: Contractor 76� <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Donk <br /> Jai �, ,� ,•r � .J.... i •v,S7`w 4� ___•_ <br /> PUMP .REPAIR: /)0 1 <br /> 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 DRILLER REPORT of the well and notify t em before putting the well use. The above <br /> informatio i true to the best o m 1 ge and belief. I WILL C R A GROUT INSPECTION <br /> PRIOR TO 0 ING AN FINAL TN E N. <br /> SIGNED TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION p <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 6��%7 2M <br />