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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> /'1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 74i- i 9 ,d <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �)r� <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 7920 W. Woodbridge Rd. CENSUS TRACT <br /> Owner's Name Ron Heier Phone 368 2062 <br /> Address 13125 I1- Stockton F City Lodi <br /> Contractor's Name Walter G. Noack Inc, License x/200 794 Phone466 0696 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN / / RECONDITION /7 DESTRUCTION /_7 - T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL. -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable :Tool Dia. of Well Excavation <br /> 10 inch <br /> Domestic/private .+Drill:ed--'F, Dia. of, Well Casing 6 inch <br /> Domestic/public Driven Gauge of CasinglO <br /> y .Type of Grout Cement <br /> Irrigation . Gravel-Pack- Depth of..Grout -Seal 0 ft <br /> 5, Other * Rotar "Z,. .: • _...,, <br /> Other Other. Information "- <br /> PUMP INSTALLATION: Contractor Walter G. Noack Inc. <br /> Type of'Pump • Barnes centrifi gn1 - - H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP REPAIR: /% State Work Done <br />,DESTRUCT_ION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure + <br /> W <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 beat of my knowledge and. belief. <br /> SIGNEDWallerackr TITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY fz� - y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ./ DATE INSPECTION BYDATE <br /> CALL FOR A .GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/7.2 1M <br />