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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />F0—P OjTFICE 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,_ 22" <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. 1862 and the Rules and Rggulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION <br />Owner's Name <br />Address 'Ps <br />Q CENSUS TRACT <br />Phone <br />City <br />Contractor's Name �, License 1:5We�d%Phone '.— <br />TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /%• <br />PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br />Other / / <br />PUMP REPAIR: / / State Work Done <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 />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 />information is true to the best of my knowledge and belief. I WILL CAIX9FOR A GROUT INSPECTION <br />PRIOR TO G UTING AIRIA FINAL INSPECTION. <br />SIGNED TITLE <br />DRAW POT PLAN 'ON REVERSE SIDE) <br />FOR DEPARTMENT USE ONLY afL <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE <br />E H 1426 Rev. 1-74 <br />s <br />INSPECTION BY <br />DATE <br />INSPECTION / <br />DATE .- -b <br />3/76 2M <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD <br />CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE <br />DOMESTIC WELL PUBLIC DOMESTIC WELL <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Industrial <br />Cable Tool <br />Dia. of.Well Excavation <br />Domestic/private <br />Drilled <br />Dia. of Well Casing <br />Domestic/public <br />Driven <br />Gauge of Casing' <br />Irrigation <br />Gravel Pack <br />Depth of Grout Seal <br />Cathodic Protection <br />Rotary <br />Type of Grout <br />Disposal <br />Other <br />Other Information 4 <br />Geophysical <br />Surface Seal Installed By: <br />PUMP INSTALLATION: <br />Contractor C.f <br />Type of Pump <br />H.P. / <br />PUMP REPLACEMENT: <br />/ / State Work Done <br />PUMP REPAIR: / / State Work Done <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 />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 />information is true to the best of my knowledge and belief. I WILL CAIX9FOR A GROUT INSPECTION <br />PRIOR TO G UTING AIRIA FINAL INSPECTION. <br />SIGNED TITLE <br />DRAW POT PLAN 'ON REVERSE SIDE) <br />FOR DEPARTMENT USE ONLY afL <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE <br />E H 1426 Rev. 1-74 <br />s <br />INSPECTION BY <br />DATE <br />INSPECTION / <br />DATE .- -b <br />3/76 2M <br />