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ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> }FOR FFICE SE: 1601 E. Hazelton Ave.., Stockton, Calif. <br />! <br /> Telephone :P' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE <br /> r ISSUED Date Issued <br /> Application is hereby made toithe San ( e <br /> Joaquin Local In rHealth District for a permit to construe <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z S L Y 7 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone _ g <br /> Address <br /> T City . cd <br /> Contractor's Name "= <br /> N License # J ?�_ Phone <br /> TYPE`OF 'WORK (Check) : NEW WELL,-/i. DEEPEN '/ / RECONDITION s <br /> _/ / DESTRUCTION /_7 <br /> PUMP`INSTALLATION,/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> "''Other / / <br /> Is <br /> DISTANCEfTO NEAREST: SEPTIC TANK p�STEI�I'RLI�NEr' PIT PRIVY <br /> SEWAGE DISPOSAL ESSPOOL/SEEPAGE PIT OTHER ! <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Lra-d- -1- p, <br /> INTENDED USE TYPE OF WELL . <br /> IndustriaCONSTRUCTION SPECIFICATIONS N <br /> l` Cable <br /> �}D . Taoln ' <br /> /41 <br /> xavato " <br /> pvae <br /> Drilled Dia. of Well Casing ih <br /> r ...Domestic/public ' Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal � f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal yP <br /> Other w` Other Information <br /> Geophysical` Surface Seal Install d B !/7 <br />'UMP INSTALLATIONi Contractor <br /> TYPe.3 of Pump <br />'UMP REPLACEMENT: State Work Done` . `'.t Z <br /> UMP REPAIR: State Work Done <br /> ESjRUCTION OF WELL: We11.'4Diameter a <br /> Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to .comply with all laws�:and regulations of the San Joaquin Local Health District ) <br /> ad the State of California pertaining ta!"6t regulating well construction. Within FIFTEEN DAYS <br /> fter complet'on of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLER REPORT of the well and no <br /> them before <br /> nformatabove <br /> ion s truput <br /> e to the best of. my knowledge and belief. I WILL CALL FOR A GROUT putting4the well in use. eINSPECTION <br /> LIOR TO G UTING ANDA FINAL INSPECTION. v <br /> EGNED u <br /> TITLE <br /> (, (DRAW.,PLOT.,PLAN)ON .REVERSE ..SIDE) <br /> 1ASE I ! t` FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY DATE 7 <br />)DITIONAL COMMENTS: Q ? <br /> P S I GRO T INSPECTI N II IN INSPECTI N <br /> fSPECTION BY DATE INSPECTION BY DATE <br /> k--H 1426 Rev: 1-7 4/661 dee <br /> GU.A,�ec %/r �/S 1 /77 Jnr <br />