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SAN JOAQUIN�VOCA2-HEALTH DISTRICT <br /> FOBrOFFICE USE: 1601 E.' Hazelton Ave..,-;Stock.-ton, Calif. <br /> TZphone. (209) 466-6781 <br /> APP CATION FOR WEII` CONSTRUCTION OR PUMP PERMIT Permit No. <br /> / THIS PERMIT. EXPIRES I YEAR FROM DATE ISSUED Date Issued 11-17-21 <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. 1842-and heRulea and Re ulaticma f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owners Name Phone ' <br /> .r/yt ' <br /> Address - - 7 4-W - ��,. „ _..,,.,. . .� City . <br /> Contractor's Name License # Phone-SZ2-43/• <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/-T RECONDITION %-f DESTRUCTION /_7 <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMPr REPLACEMENT /? <br /> .3 . . Other / / <br /> DISTANCE TO NEAREST; SEPTIC TANK ���' SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD /a '� CESSPOOL/SEEPAGE PIT OTHERCU�/60� € <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC.WELL <br /> INTENDED -USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />_j::�` Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal 157o <br /> e2 4' <br /> Cathodic Protection _,�/ Rotary Type of Grout ' r <br /> Disposal . Other . Other Information ' <br /> Geophysical Surface Seal Installed BY: <br /> f <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Donee <br /> f <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF..WELL: Well Diameter Approximate Depth �f <br /> Describe MateriaAnd Proce ure <br />.I hereby agreeto comply with all laws and regulat s of the San aaquin Lnnal 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 Districta <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- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND V_ANAL INOECZ19N. 1,2 <br /> SIGNEDTITLE t <br /> (DWPTXff PLAN ON 1&YRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDpvtATE' r 171 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II ROUT INSPECTION PRASE001I INSPECTIPP <br /> INSPECTION BYTE. INSPECTION BY DATE <br /> E H 1426 4/75 2M /1 <br />