Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 7U F:LCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7.S"-/lam <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 17067 Hiway 88 CENSUS TRACT <br /> Owner's Name David Thompson Phone 267 5122 <br /> Address _ Rt• 1 Box 35E, Sutter Creek, 95685 City Sutter .Creek <br /> Contractor's Name W. G. Noack Ince License # 200794 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL #*7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION K PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other / / <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK • SEWER LINES PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD >-6 47-CESSPOOL/SEE0AGE 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 12 inch <br /> — Domestic/private Drilled Dia. of Well Casing 8 inch <br /> Domestic/public Driven � _Gauge,. of Casing 12 a ,e Kaiwell <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Cathodic Protection Rotary Type of Grout Cement O.d <br /> Disposal Other Other Information C*6 <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor San Joaquin Pum• Coe, Lodi <br /> Type of Pump Submersible H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPREPAIR: L7 State Work Done, <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Up to owner 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 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY a <br /> PRASE I '�L/ <br /> APPLICATION ACCEPTED BY ���'G%I DATE <br /> ADDITIONAL COMMENTS: ' _ 114 <br /> PHASE II GROUT INSPECTION PHASEAkIl INSPECTION <br /> INSPECTION BY DATE ._4,-7.�z INSPECTION BY DATE ?.6 <br /> `t E H 1426 Rev. 1-74 1-74 2M <br />