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t 'dWW� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I // Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 17067 E. Hiway 88 CENSUS TRACT <br /> Owner's Name David Thompson Phone 267 5122 <br /> Address Rt. 1 Box 35 E City Suter Creek <br /> Contractor's Name W. G. Noack Inc. License #200 794 Phone 466 0696 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /*7 RECONDITION *-V DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR f_1 PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ; 60 ft. SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ** Cable Tool Dia.rof Well Excavation 8 inch <br /> ** Domestic/private Drilled Dia. of Well Casing 7 inch <br /> Domestic/public Driven Gauge of Casing 12 gua e Kaiwell <br /> Irrigation Gravel Pack Depth of'. Grout Seal None <br /> Cathodic Protection Rotary Type' of Grout <br /> Disposal Other Other Information <br /> rGeophysical r-- Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor San Joaquin P=P- Coe <br /> Type of.Pump Submersible H.P. I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: ` 1_7 State Work Done - h <br /> ESp —TTRUCTION OF WELL: Well Diameter - �~ - -ly y FApproximate 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 ,eonstructi.on. 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. :— <br /> SIGNED .14. Noack Inb. b ' ___. TITLE Salesman <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .3 -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II CTI N PHASE III FINAL INSPECTION <br /> Y`�INSPECTION BY DATE 7715r INSPECTION BY DATE - -7d_ — <br /> ' ; 1-74 2M <br /> .it E H :L426 Rev. 1-74 � � � � - <br />