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_ T''" " SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR: PROM DATE ISSUED Date Issued <br /> 4r_ (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 /> I <br /> JOB ADDRESS/LOCATION _3501W.—Wakefield S.E. Corner CENSUS TRACT I <br /> Owner's Name Ajpinf_Packing Phone 477-2691 <br /> Address350 W. Wakefie d I <br /> City Stockton <br /> Contractor's Name _alter G. Noack License 4200794 Phone 948-8817 <br /> x <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN / J RECONDITION /_/ DESTRUCTION /_ <br /> it PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT 1_7 <br /> Other f/ / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 4 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 (^ <br /> Domestic/private Drilled Dia. of Well Casing <br /> ° -tDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information ' <br /> Geophysical_ 1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Walter G. Noack <br /> , <br /> Type of Pump -Turb e H.P. 477. 2691 ,s <br /> PUMP REPLACEMENT: / / State Work Done`- <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth . j <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. pertaini..ng 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 above4. a <br /> information is true to the best, of my knowledge and belief. I WILL CALL� FOR A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A FINAL-INSPECTION. <br /> SIGNED TITLE <br /> 17 (IjRAW PLL T PLAN ON RE FRSE SIDE) `:j, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED -BY DATE ,. <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> F <br /> i 1CP <br /> r i 2 <br /> k E H 1426 Rev. 1--74 - <br />