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AN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> // Telephone: (204) 466-6781 <br /> AP -KATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 '/Q�-.. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 7 -1�- <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. 1562 and the Rules and Regulations of the San Joaquin Local Health.Distri-ct.. <br /> JOB ADDRESS/LOCATION 22530 East Hwy CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> City .kn <br /> Address <br /> License # 20()79g, 'hone q4R 581 .7 <br /> Contractor's Name <br /> TYPE OF WORK (Check); NEW WELL /7 DEEPEN I / RECONDITION /? DESTRUCTION F7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 /> k Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> F Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> \ <br /> PUMP INSTALLATION: Contractor Walter G. Noack H.P. "l0 <br /> Type of Pump Submersible <br /> i PUMP REPLACEMENT: / / State Work Done y\ <br /> PUMP-LiEPAIR.�, .. / -/--Stat;e..Work Done Pull um re lace motor, leads install' . <br /> F' Approximate Depth '; <br /> DES-TRUCTION 'OF WELL: Well Diameter <br /> Describe Material and Procedure a, r <br /> I :hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dtst:ri:ct� <br /> and the State of California pertaining to or regulating well"construction. Within FIFTBZN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri.c,t 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 II.4SPECTION. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. = } <br /> SIGNED , TITLE . <br /> � .. <br /> 'ON ZtSE SIDE <br /> s r FOR DEPARTMENT USE ONLY <br /> PHASE I ' :`s t l DATE .2- <br /> APPLICATION ACCEPTED-BY <br /> ADDITIONAL (,;,OMMTS: " <br /> PHASE II .GROUT INSPECTION PHASE III FINAL I1dSPECTION:: <br /> IN5PECTIOM BY DATE INSPECTION BY DATE -� <br /> M ti 76 <br /> E H 1426 Rev. 1. 74 <br />