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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> %,THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-11-25- <br /> (Complete <br /> -1125-(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 Joaquini <br /> County Ordinance an Rule Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCA ION CENSUS TRACT <br /> Owner's Name Phone , X35 by CA <br /> Address P City <br /> Contractor's Name License # O13 Phone �ld. / <br /> C <br /> -177 <br /> TYPE OF WORK (Check),., . NEW WELL '/AO DEEPEN /7 RECONDITION /-7 . DESTRUCTIOI�� ...,. <br /> PUMP INSTALLATION -E/ PUMP REPAIR 1-7—PUMPREPLACEI�NT: 1 <br /> Other <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY S <br /> - SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia, of Well Excavation //" <br /> V 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 Protection Rotary Type of Grout ese &4":t�� <br /> Disposal Other Other Information ' - <br /> Geophysical . _ Surface Seal Ins talled 'B r <br /> PUMP' INSTALLATION: Contractor -' <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: . / / State Work Done P OPA <br />=Pump . Av _.._ /_/ `5�e- Work Done <br /> REPAIR:: _ <br /> .Jr <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 /> i-,and the State of California pertaining to or regulating well "construetion. Within FIFTEEN DAYS <br /> I <br /> fter completion of my work 61} a new well, I will furnish the San Joaquin Local Health District a i <br /> WEII 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 TOG OUTING ANDA AL INSIMCTION, <br /> SIGNED TITLE <br /> j DRAW T PLAN ON REVERSE SID ' <br /> F R DE MENT,USE ONLY <br /> PHASE I --� <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL C0 <br /> POUT INSPECTION ' PHASE Ii FINAL .INSPECTTON <br /> INSPECTION DATE .S INSPECTION BY DATE <br /> R R I L26 'a 1_7 A may' h/75 2K <br />