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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '�d <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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3921 E. 41.rmstrong Rd. CENSUS TRACT <br /> Owner's Name Chas. E. Walters Phone 368 4523 <br /> Address 3921 E. Armstrong Rd. City Lodi <br /> Contractor's Name W* G. Noack Inc. License # 200794 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL /;T DEEPEN /7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR -7 PUMP REPLACEMENT F7 <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 ft. SEWER LINES 85 1t• PIT PRIVY <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 inc <br /> ** Domestic/private Drilled Dia. of Well Casing 5 inc <br /> Domestic/public Driven Gauge of Casing 01ass 160. plastic <br /> Irrigation Gravel Pack Depth of Grout Seal ft. - <br /> Cathodic Protection *7' Rotary Type of Grout — Cement `"`�� <br /> Disposal Other ` Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump 3erkele;t jet pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /_ 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 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOffROUTIN�GAND A FINAL INSPECTION. <br /> SIGNED l ( -� .,,;,. TITLE Salesman <br /> DRAW PLOT ROME <br /> VERSE SIDE <br /> DENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPT B DATE - <br /> / AK <br /> ADDITIONAL COMMENTS: .— <br /> PHASE II GROUT INSPECTI©N PRAS I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A <br /> W7GAA_, DATE /' 77a 9k <br /> E H 1426 Rev. 1-74 5 2M <br />