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SAN JOAQUIN LOCAL HEALTH. DISTRICT , <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7-a -p <br /> /ITHISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 moo- 7 7 i <br /> (Complete In Triplicate) <br /> Application is hereby made toFthe 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 and1the Rules and Regulations of the San Joaquin Local Health District. n <br /> JOB ADDRESS/LOCATION 14 S. _Xaiaer lid, CENSUS TRACT t <br /> Phone <br /> Owner's Name Norman kllried <br /> AddressCity <br /> Contractor's Name �,9�+or G Ncac►k _ <br /> License # 20Q744 Phone.`^q48-8Rj 7 <br />-TYPE -OF WORK= (Check) : NEW�WELL-a-/:/-. DEEPENS/-/=�REGONDITT-ON-�/��DESTRUCTION�=/?. <br /> PUMP INSTALLATION/ / PUMP REPAIR/X/ 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 t Cable Tool Dia. of Well Excavation <br /> ---X— Domestic/private �[ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information ' <br /> Geophysical �` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Walter G. Naack , <br /> Type of Pump submersible H.P. { _ <br /> fState Work Done <br /> PUMP REPLACEMENT: <br /> - - . State Work Done <br /> PUMP .REPAIR: / - <br /> switch proximate+ Depth <br /> DES-TRUCTION OF WELL: .. Well-Diame.ter.. <br /> T Describe Material and Procedure <br /> E <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 wrell'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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVATING AND 4,JINAL IN PECTION. <br /> SIGNEDRE TITLE <br /> DRAW'PLOT PLAN 'ON FRSE SI1.E) f: <br /> l - FOR DEPARTMENT USE ONLY <br /> PHASE I &; DATE <br /> APPLICATION ACCEPTED BY, <br /> i. ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> ii PHASE T OUT INSPECTION <br /> I INSPECTION BY DATE INSPECTION BY _ _ DATE .3-C"7 <br /> 3/76 214 <br /> E H 1426 Rev. 1-74 <br />