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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haxelton'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. a lap <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued-6-574 <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. kThis 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 -WoR CENSUS. TRACT <br /> Owner's. Name Rdn .:Heir_: Phone 368-2062 <br /> 13125 N. Stockton <br /> Address City . Lodi <br /> Contractor's Name Walter G, Nl ok Inc,_. License MOO 794 Phone 466-0696 <br /> TYPE OF WORK (Check) : NEW WELL / f DEEPEN /_/ RECONDITION 1-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /x:/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 f t.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 /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation t- Gravel Pack Depth of Grout Seal <br /> Other I. Rotary Type of Grout <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor Walter G. Naak Inc, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t <br /> r <br /> PUMP--,REP-A-1-R-:;&; -_�,­• <br />{ <br /> ESTRUCTION OF WELL: Well Diameter� -- , ,,.. _ �. Approximate Depth <br /> Describe Material and Procedure <br /> r 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 i The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED Walter Noack Inc. by TI <br /> (DRAW PLOT PLAN ON REVERSE SIDE <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 fy INSPECTION BY _40g2 DATE 2 •� I <br /> CALL FOR A GROUT INSPEGTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />