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,Anon Or <br /> V/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Helltfi District for a permit to construct <br /> and/or install the work herein described. Phis application is made in compliance with San Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION 5400 S. Maybeck Rd., CENSUS TRACTI <br /> Owner's Name Lawrence Del Soldato Phone L69 7901 <br /> Address 5400 S. Maybeck Rd. City Stockton <br /> Contractor's Name W. G. Noack Inc. License # 200 794 Phone 466 0696 <br /> TYPE OF WORK (Check) : NEW WELL/77 DEEPEN '/-7 RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION /_.'/ PUMP REPAIR /-7 PUMP REPLACEMENT f7 <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK256 ft, SEWER LINES 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 6 inch <br /> ++ Domestic/private Drilled Dia. of Well Casing 2z inch plastic <br /> Domestic/public Driven Gauge of Casing Class 160 <br /> Irrigation Gravel Pack Depth of 'Grout Seal 20 ft. <br /> Cathodic Protection Rotary, -- - Type of Grout Cement <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP .REPAIR: /7 State work Done <br /> ,DESTRUCTION 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 <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 ofmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND Al'FINAL INSPE ION. <br /> SIGNED W. G. Noack by / gay, TITL Q <br /> --- -(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DA Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONi PHASE IW/MAL IW/FINSPECT N <br /> INSPECTION BY _ DATE INSPECTION BY DATE 2 <br />