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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FORrOFFICE USE: 1601 Ea Hazelton Ave. Stockton Ca _�..... <br /> lig. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sart 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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 12650 Hibbard CENSUS TRACT , <br /> Mier°s Name A� Le Hudson: Phone 323 2735 } i <br /> Address 838 Wo 157th Ste <br /> City Gardena, Ca. � <br /> Contractor;e.a Name W G• Noack & Son. License #200 794 Phone"6`0696 <br /> WE <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/_ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATIDN / / PUMP REPAIR / / PUMP REPLACEMENT I T <br /> Othei <br /> ,DISTANCE TO NEAREST: SEPTIC TANK 6,. ft,. SEWER LINES106 f'-t. PIT PRIVY <br /> SEWAGk DISPflSAL`�FIELD CESSPOOL/SEEPAGE PIT-177— ft. OTHER � <br /> PROPERTY LINE - PRIVATE-DOMESTIC`WELI;" PUBI.IC DOMESTIC WELL <br /> INTENDED USE €TYPEIOF WELL`- ; CONSTRUCTION SPECIFICATIONS <br /> industrial i Cable Tool. Dia. of Well Excavation 14 inch <br /> Domestic/private, i Drilled Dia. of Well Casing —.... lo' ine h- <br /> Domestic/public _�I Driven Gauge oftCasing 1 12 a e <br /> Irrigation 4 Gravel.Park De th of Grout Seal <br /> 1• -. p 0 ft. �. # <br /> Cathodic Protection 'Rotary Type of Grout 'Cement k <br /> DisposalOther- +Other Informations ; <br /> Geophysical Surface Seal Installed BV: <br /> PUMP INSTALLATION: Contractor � • _ _ _ <br /> Owner.j <br /> Type of Pump Seara�-submersible k H.P. 1z <br /> PUMP REPLACEMENT: / / State Work Done �f <br /> PUMP ,.REPAIR--: SWo <br /> ./��. .; tate= rk Done <br /> ES;TRUCTION 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. toior 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 puttingthe- well in.use. The above <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTTNG AND A FIN INSPECTI p <br /> SIGNED` , TITLED,JGa. a�. �, <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR bEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC IQN PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE jS INSPECTION BYa DATE <br /> E H 1426 Rev. 1--74- <br /> 1-74 2M <br />