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f SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> f FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 3 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 <br /> (01ag <br /> i (Complete In Triplicate) <br /> I 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/I,OCATTONVeritas Manteca Ca. CENSUS TRACT <br /> Owners Name Mike Carne <br /> Phone <br /> Address VeritasCity <br /> Manteca, Ga. <br /> Contractor's Name Stanisiaus km & Machine' Cor Kati n License # Phone ' <br /> I <br /> TYPE OF WORK' (Check): NEW WELL/_7 DEEPEN -/—/ RECONDITION /_7 DESTRUCTION i <br /> PUMP INSTALLATION /-,/ PUMP REPAIR / / PUMP REPLACEMENT /_7 ; <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER .LINES PIT PRIVY <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private r Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> x 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; <br /> Contractor Stanislau <br /> on=- <br /> Type of Pump johrigtgn H.P. -PUMP REPLACEMENT: .REPLACEMENT / / State Work Done + <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> DES-TRUCTION OF WELL:- Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />,, I hereby agree to comply withlall 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 oii 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_knowle�$e and elief. I WILI�CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND NALITNSPECTION. 3 <br /> SIGNED <br /> TIE <br /> il(DkAw P T' PLAN ON RE RSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> " <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL IN._SPE�CTIPN <br /> INSPECTION BY DATE INSPECTION BY DATE e:F <br /> 7113-78 1941,., cel <br /> E H 1426 Rev. -I-74 '1 376 2M <br />