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Glyj / SAN JOAQUIN LOCAL HEALTR DISTRICT <br /> d <br /> FOR OFFICE USE: !/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) f <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 Regulations of the San Joaquin Local Health District. <br /> JOH'ADDRESS/LOCATION 100 , S A V 15 CENSUS TRACT <br /> Owner's Name Z I I d a _1 0 WE &// f� Phone 6 /67 <br /> Address , n 12r City kr�_ <br /> Contractor's Name l r , CC) License #94/i�aZ Phone -//- <br /> t <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN /_7 RECONDITION DESTRUCTION /_' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> --Other h <br /> �E <br /> DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES PIT- PRIVY Qj <br /> SEWAGE DISPOSAL FIELD � 'CESSPOOL/SEEPAGE PIAT OTHER �^ <br /> f <br /> INTENDED USE ,� TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I J ! Cable Tool Dia. of Well Excavation z �-; <br /> Domestic/private t Drilled Dia, of Well Casing Q <br /> Domestic/public:, f t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 's LA , <br /> _ Other s I Rotary Type of Grout <br /> A Other Other Informationt1t9R!L3,9.sf_ <br /> L 4�' 'W T d u C U� 0y sAp)P19S C !? 7Z-S7 SAIE, 1. <br /> PUMP INSTALLATION: Contractor C <br /> Type ofiPump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> # fi F• <br /> ESTRUCTION OF WELL: Well Diameter _Approximate Depth��--- --� <br /> Describe Material and Procedure .---- <br /> I <br /> rocedure - -I hereby agree to comply wit-h `411 laws and regulations of the San Joaquin Local Health District t <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: ( r <br /> SIGNED TITLE-,,-_ <br /> (DRAW PLOT. PLAN ON REVERSE. SIDE <br /> FOR DEPARTMENT USE ONLY } <br /> PHASEI ...,..,.._...,,_..._�....._.._a,.. .�_ .. -. . <br /> APPLICATION ACCEPTED BYA:)11011 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY ±reo DATE _) ,-2V!7 INSPECTION BY DATE 1�{ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 7/72 1M <br />