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f _ <br /> N� 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 PURR' PERMIT Permit No. 72=may <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 <br /> (Complete In Triplicate) i <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 /> rJ1243 ' • / sf��i�•. 8SS-ZrO_oS 3 <br /> JOB ADDRESS/LOCATION Mile Rd and Davis Rd. CENSUS TRACT <br /> Owner's Nacre Cortopas.si .Farms Phone 948-4022 <br /> Address 11 292 N. Alpine Rd. City StocktD n, Califof' <br /> Contractor's Name Walter G. Noack & Son, Inc. License # 200794,Phone 948-8817 <br /> r 1 <br /> TYPE OF WORK (Check); NEW WELL -/-7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <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 /> Domestic/public Driven Gauge of Casing <br /> X,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: Contractor <br /> ractor Walter G. Noack & Son, Inc. t <br /> Type o€m Pump Tu a H.P. 19Q <br /> + � - , - <br /> PUMP REPLACEMENT: <br /> /X/ SCate-Work-Done Rep'latie 20. HP. ptamp. w•i.th:J.0-0 HP. , <br /> PUMP AEPKIR c �. /—/ -State m r W .k :_ �� <br /> oDone <br /> DES.TRU_CTION OF_WPLL: Well Diameter Approximate 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 'construction. Within FIFTEEN DAYS r <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 GRQU7INC17AND A4FINAL JILSPECTION,. <br /> SIGNED TITLE Office Manager <br /> DRAW MT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ d� i <br /> ADDITIONAL COMMENTS: -ii 7 !,r f! . h.-/5 C , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ? -7,7 <br /> r' <br /> E H 1426 Rev. -I-74 <br /> 3/76 2M M <br />