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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 05R*rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,j= 3 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7S' <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 n Roberts Island CENSUS TRACT <br /> r z <br /> Owner's Name Angelo Petrini Phone465 8678 <br /> Address 10229 Crocke.r_YRd. City Stockton <br /> Contractor's Name W. G. Noack. Inc. } * ' a I License #.200794 79 Phone 466 o696 <br /> TYPE OF WORK -(Check): NEW WELL .4*7. DEEPEN '/-7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7PUMP 'REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 196ft. SEWER LINES 202ft. 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 8 inch <br /> *** Domestic/private Drilled Dia. of Well Casing _ 3 inch <br /> Domestic/public Driven Gauge of Casing Class-160, plastic <br /> Irrigation Gravel Pack Depth of Grout Seal -25 ft. <br /> Cathodic Protection *** Rotary Type of Grout Cement <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> .s <br /> Type of Pump H.P. <br /> .f ':�A �, ,..'- - _ fir.,,.-,.F....,c.� .....,.. r�nr-.x-•�_-.......,. ,-, <br /> PUMP REPLACEMENT: / / 5 tate `Work-Done— ---- _ f i <br /> PUMP :REPAIR: /77 State Work Done r <br /> E&TRUCTION OF WELL:" Well Diameter Approximate Depth <br /> Describe'Mater"ial 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 Californi-a-pertaining-to-or-regulating well constxuction:"`"°'Within FIFTEEN DAYS J <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 .weil 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 GROUTING -AND A FINAL INSPECTION. <br /> SIGNED "' �.. TITLE j4' ..t,ik�i..� <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> r <br /> ADDITIONAL COMMENTS: <br /> V PHASE II GROUT INSPECTION :', PHASE III/FANAL INSPECTXbNj�f <br /> INSPECTION BY DATE INSPECTION'BY DATE o I <br /> 5R : E H 1426 Rev. I-74 ; _ -_ '1-74 2M .-,- <br /> R } <br />