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SAN JOAQUIN LOCAL HEALTH DISTRICT � T <br /> FOfif FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued z3-7-5— <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District :dor a permit to construct <br /> and/or. instal,l the work herein described. This application is wade in compliance with San Joaquit <br /> County Ordinance. No-. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION „o. - 2?Lt)t ~ <br /> IL CENSUS TRACT <br /> i Owner's Name Zuckerman- Mandeville Inca Phone 465 7213 <br /> Address P.O. Box-48 <br /> CityStockton „ <br /> Contractor's Name W. G. Noack Inc. License # 200 794 79 Phone 466 0696 <br /> TYPE OF WORK (Check): _ NEW WELL /_7 DEEPEN / % RECONDITIONF DESTRUCTION <br /> E 3 'PUMP INST TION; / REPAIR / / REPLAC <br /> Other m k.. t BUMF' T .�Lf r <br /> WI—STANCE TO NEAREST: SEPTIC TANK ........... <br /> 5A <br /> - - [11: LINES PIT PRIVY <br /> # SEWAGE`DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY'�LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �9 <br /> INTENDED USE TYPE. OF WELL ' <br /> Industrial CONSTRUCTION SPECIFICATIONS :N <br /> Cable Tool j .:Dia. of Well .Excavation inch <br /> -7._ Domestic/private �-.Drilled Dia. of Well Casing 2 inch <br /> Domestic/public �� ' <br /> Irrigation Driven lGauge of Casing «375 <br /> Gravel Pack iDepth of Grout Seal 0 ft. <br /> Cathodic Protection ` <br /> Dis os Rotary Type of Grout Cement <br /> p a1 , , � <br /> -`--- Others Other Information <br /> Geophysical . Surface Seal Installed B : f <br /> PUMP INSTALLAT 0 � <br /> _Contzacto�r-; None <br /> f y ' Tye of YPunip. <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP '.REPAIR: L7 State Work Done <br /> ES:TRUCTIONOF WEL LI Well Diameter <br /> Describe Material. and Procedure Approximate Depth <br /> I hereby agree-to comply with all laws and regula'tioris of the `San Joaquin <br /> District k <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 iir.use.. The above <br /> information is true "to the best of my.knowledge and belief. L CALL FOR A GROUT INSPECTION <br /> PRIORito GROUTING.``AXTD AI WIL <br /> FINAL; IN PECTION, <br /> SIGNED Wo G. Noack Inc. by - TITLE Salesman <br /> PLOT PLAN ON REVERSE.SIDE . _ f fi <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL,rCOMMENT -: - TE <br /> PHA O EC - Y '� _ pS I INSPECTION <br /> INSPECTION BY DATE — 'INSPECTIONBY <br /> DATE C ZZ5 <br /> E H 1426 . ev. 1-74 <br /> 7_74 7u <br />