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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _�,Z��✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issue 76- 7G <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 AOCATION 1039 Paloma. St. CENSUS TRACT <br /> Owner's Name Ray De Heus Phone 477 1688 <br /> Address _ 1039 Paloma St. City Stockton <br /> Contractor's Name Wo G. Noack Inc. License #200794 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL ',G7 DEEPEN '/ RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION ffl7 PUMP REPAIR'/—/ PU1+fP REPLACEMENT %f <br /> Other <br />(DISTANCE 'TO NEAREST SEPTIC TANK 110 SEWER LINES 120 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 inch <br /> Domestic/private Drilled Dia. of Well Casing 5 inch class 170 plastic�' <br /> Domestic/public Driven Gauge of Casing Class 160 plastic <br /> Irrigation Gravel Pack Depth of Grout Seal _ 2 ft. <br /> Cathodic Protection Rotary Type of Grout Cement <br /> Disposal Other Other Information <br /> Geophysical rte- Surface Seal Installed By* <br /> W. G. Noack Inc. <br /> PUMP INSTALLATION: Contractor W. G. Noack Inc. <br /> Type of Pump Fairbanka Morse, submersible H.P. 12 <br /> PUMP REPLACEMENT; State Work Done <br /> PUMP ,.REPAIR: /% State Work Done <br /> bE&T, _ RUCTION OF WELL: Well Diameter Appxoximate 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,best -af. my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL 'INSPECTION. <br /> SIGNED �Q_Et �„� TITLE Gz Cs�/ <br /> + DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II INAL USPECTIO <br /> INSPECTION BY DATEINSPECTION BY <br /> DATE 8 b <br /> E H 1426 Rev. 1-74 <br /> 4/75 2M <br />