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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: 1601 E. 'Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N°' " <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued <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 /> k , County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 10229 N. Hit ret h Lane CENSUS TRACT , <br /> Owner's Name Del �Lon Phone '931 470 <br /> f Address - <br /> 102 N. Hit dreth Lane City ,, 'Stockton:: <br /> Contractor's Name W. G. 'Noack-Inc. <br /> License #200794 Phone 466 0696 <br /> I TYPE OF WORK (Check): NEW WELL,-L7 DEEPEN '/7 RECONDITION -J7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIRPUMP REPLACEMENT /? <br /> /� <br /> l _Other—/- 7,. <br /> DISTANCE TO NEAREST: ' SEPTIC STANK 50 ft.. SEWER LINES : PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/-SEEPAGE"PIT'--" OTHER \ <br /> F - - - -PROPERTY LINE - PRIVAff 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�Diar' !Of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 'Cathodic Protection *"`* Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> W.' G. Noack Inc. <br /> 4 <br /> mers� <br /> Type,of< Pump bu a H.P. <br /> PUMP REPLACEMENT:. / / State Work Donee Pull pump, deepen taeil, reinstall pump <br /> PUMP .REPAIR: / / State Work. Done j <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 /> r-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 °f. my.knowledge and belief. -1,WILL CALL FOR A GROUT INSPECTION <br /> . PRIOR jq GROUTING AND A FINAL INSPECTION. <br /> SIGNED (, w�l�AI�. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ARTMENT USE ONLY <br /> PHASE ;I <br /> APPLICATION ACCEP 1if f? R 13 DATE - S <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES INSPECTION BY <br /> �—�— — -DAT <br /> - 5 2M <br /> '.v it ILIA ve 1_74 <br />