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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7`CoQ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-72,,W--0J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued:?2Z-22 <br /> - <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 shade 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 _13 _. CENSUS TRACT <br /> Owner's Name Phone yds-- ffe <br /> Address City <br /> Contractor's NameLicense �� fYe JyFhone 7 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION %f DESTRUCTION /- <br /> PUMP INSTALLATION firl PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3o-0 ` SEWER LINES PIT PRIVY - <br /> _- SEWAGE DISPOSAL FIELD C�SSPOOI:/SEEPAGE"PIT_ - OTHER `- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL :- CONSTRUCTION SPECIFICATIONS <br /> I dustrial 1,e'Ca-ble Tool Dia. of Well Excavation / X <br /> Domestic/private Drilled Dia. of Well Casing ;?A, <br /> Domestic/public ` .. Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectRotary Type of Grout g so-et <br /> Disposar.. ion ` Other Other Information ' <br /> Geophysical + ISurf ace Seal Installed BY: a,--oW. --n,�M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. °7, J <br /> PUMPREPLACEMENT: - / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DES-TRUCTION-OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure AW <br /> I hereby agree to comply with all laws and regulations pf-- theJRSan Jo4gdin-Local Health District <br /> and the State of Califordia 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 DRILLERS REPORT of. the.well-`Ad notify thein bef r putting-tht*ell. in.use.... The above <br /> information-is' t e o the;best of"nny.,7know'ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR'TO''GROUTIN D'A F I <br /> SIGNED` - 7, TITLE <br /> (DRAW PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I • <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL-COMMENTS: <br /> PHASELIL.SE0,VT INSPECTION. PHASE III FINAL INSPE IO <br /> INSPEChON BY DATES INSPECTION BY DATE f <br /> E H 1426 Rev. -1---.7 - - ;r . -. <br />