Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL C014STRUCTION OR PUMP PERMIT Permit- No. 75-1-�1 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -f�-7f <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 13430 N. HiwaX 88 CENSUS TRACT <br /> Owner's Name Ferdie Sievers Phone 727 5896 <br /> Address 15191 E. Hiway 88 City Lockeford <br /> Contractor's Name W G. Noack Ino. License # 240 794 Phone 466 0696 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 -� <br /> PUMP INSTALLATION REPAIR J / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 87 ft. SEWER LINES 97 ft. PIT PRIVY O <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 10 inch <br /> Domestic/private Drilled Dia. of Well Casing 5 inch <br /> Domestic/public Driven Gauge of Casing _Class 160, plastic A <br /> Irrigation Gravel Pack Depth of Grout Seal 0 ft. <br /> Cathodic Protection Rotary Type of Grout Cement <br /> ,Disposal , Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Wo G. Noack Inc, <br /> Type of Pump Fairbanks-Morse submersible H.P. <br /> PUMP REPLACEMENT: / / State Work Done ;- <br /> PUMP .REPAIR: 47 State Work-Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the SanJoaquinLocal Health District <br /> and the State of California pertaining to or regulating well 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 CAL€. FOR A GROUT INSPECTION <br /> PRIOR TO 5ROYJING AND A FINAL INSPECTION. <br /> SIGNED 41, TITLE , , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �. <br /> -- -- _ <br /> FOR DEPARTMENT USE ONLY — - - �— <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ., DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 . D 74 2M <br />