Laserfiche WebLink
t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOKOFFICE USE. /111601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ,M <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1N (Complete In Triplicate) <br /> Appliaaition 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 12804 West Byron Rd. CENSUS TRACT <br /> a� <br /> Owner's Name Fred Sar enti Phone 835 1234 <br /> Address 612$10 West Byron Rd. City Tracy <br /> Contractor's Name W. G. Noack Inc. %'t '-Li'ceinse 20 794';'Phane466 0696 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /? RECONDITION fTF DESTRUCTION f7 <br /> PUMPi, INSTALLATION / PUMP REPAIR /� PUMP REPLACEMENT f-70 their I / <br /> DISTANCE TO NEAREST: SEPTIC TANK 105 t.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDILS ft. CESSPOOL/SEEPAGE PIT OTHER Q <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 <br /> Domestic/private Drilled Dia. of Well Casing inch <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information ;1 <br /> Geophysical Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Y Contractor W. G. Iuoack,'.Ixz1e:r'1 <br /> —CTyp of-pump Fairbanks Morse shallow we 11 A.P.' A-2 <br /> PUMP REPLACEMENT: <br /> �/ /� State Work Done ;x <br /> k-,PUMP :REPA-1-R-' / i ..St`ate-'Work Done- <br /> 7777 ��T... _ _ � •_ �, �, W <br /> pES•TRiJCTiON OF WELL:. Well Diameter Approximate Depth <br /> 1';L;Describe-Material and Procedure i <br /> I hereby agree to comply wfth,.al.l.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 wel]wand notify ahem before putting. the, ,sell in.use.. The above . <br /> information is true to the-%est of ny knowledge and belief. I WILL SaL FORA GROUT INSPECTION <br /> PRIOR 2GROUTIgG AND A FINAL INSPECTION":"< <br /> TITLE <br /> it (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR-DEPARTMENT-USE-ONLY--4 <br /> PHASE I <br /> APPLICATION ACCEPTED :BY` ;"t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION _ �1 `;� ;�? P S II NAL INSPECTION <br /> INSPECTION BY L -- DATE.. J INSPECT`IOIQ. BY DATE ° -IS'7S! <br /> t E H .3426 Rev 1-74 i' 1-74 2M - <br />