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rLJN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 160. S. Hazelton Ave, , Stockton, Cal <br /> Telephone: (209) 466-6781 �- b <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 1 7p 9!° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/O r2 <br /> (Complete In "Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth District for a permit to construct <br /> and/or install the work herein described.nd Resulationsapplication <br /> the SaneJoaquin Localcompliance <br /> Health San <br /> DistrictJoaquin <br /> county Ordinance No. 1862 and the g <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> �f_� j Y <br /> r' Phone <br /> Owner's Name <br /> S-0 <br /> City <br /> Address . <br /> Contractor's Name <br /> (� cense Ql Q Phone --�� <br /> TYPE OF WORK (Check): NEW WELL JZ DEEPEN 1-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /ZAP REPAIR / / PUMP REPLACEMENT ITT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LIAES.S TT PRIVY <br /> SEWAGE DISPO AL FIELD <�'o�t-CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia: of Well Casing <br /> y. <br /> _Ik12 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack, -. Depth of GroutSe <br /> Cathodic Protection Zotary Type of Grout <br /> Disposal Other -_ Other Informatio <br /> Geophysical Su.rfAce,.%Sea1 Installed B E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: _ /_7 State Work Done <br /> 74 6- <br /> Approximate Depth <br /> STRUCTION OF WEL Well Diameter <br /> Describe Material and Procedure <br /> I hereby agre�to comply with all 1 s and regulations of the San Joaqui Local Healt4 K,441kelx 7V 777-_7 <br /> h 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 DRILLERS REPORT of the well and notify them before putting the_well in-use.• The above <br /> info on is true to the � : wl dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TING AND A FIN I N 4 <br /> SIGNED 1 TITLE �� CA-1 — <br /> LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHA DATE <br /> APPLICATION CCEPTED BY <br /> ADDITIONAL COMMENTS"fw`� <br /> P INSPECTION P 0A1. INSPECTINSPECTION BY DATE - INSPECTION BYDATE <br /> E H 1426 Rev. 1•-74 <br />