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0,t-w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 2--72 <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 Box 1201 3P11"iY� I;sve 'd. CENSUS TRACT <br /> Owner's Name Louie Vierra Phone 477 6150 <br /> Address Box 1201 Wing Levee Rd. City Stockton <br /> Contractor's Name Welter G. Noack Inc. License # 200794 phone 466 0690 <br /> TYPE OF WORK (Check) : NEW WELL /*-*7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .�4"ftp SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial __ Cable Tool Dia. of Well Excavation 7 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 _ 30 feet <br /> Other T Rotary Type of Grout Cement _. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter - - Approximate Depth t <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 <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. <br /> SIGNED ' <br /> r G. Nock Inc. b TITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE r�l <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTIO P INAL INSPECTION <br /> INSPECTION BY DATE g INSPECTION B ATE <br /> CALL FOR A GROUT INSPECT ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />