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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR,OFFICE USE: 1.601 E:. Hazelton Ave. , Stockton, Calif. <br /> 'Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. AL 61-2/ <br /> - THIS PERMIT EXPIRES 1 YEAR, FROM DATE ISSUED Aate Issued <br /> ;1 (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 Joaquit <br /> County Ordinance No. '1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LQCATIQN 535�iMand Drive CENSUS TRACT ' <br /> Owner's Name Vierra Bros,. Phone • 465 111+67, <br /> Address 5 <br /> 353 Inland-Drive City Stockton- <br /> 'Contractor's <br /> tockton-'C4ntractor's Name Ytp C. Noack Inc* h i'License #200 794 Phone466 0696 <br /> f TYPE OF WORK (Check): NEW WELI, /w-7* DEEPEN — <br /> RECONDITION_./? DESTRUCTION f7 <br /> PUMP INSTALLATION /—/, PUMP REPAIR /� ' PUMP REPLACEMENT <br /> I Other 'lest welT to find better�ualit �_ <br /> DISTANCE TO NEAREST s_".-SEPTIC TANK' + 1. . O SEWER LINES PIT .PRIVY <br /> =jk SEWAGE DISPOSAL FIELD~ ' r�+, CESSPOOL/SEEPAGE PIT OTHER (n <br /> PROPERTY LINE -,:PRIVATE DOMESTIC WELL ' . .PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL €i CONSTRUCTION SPECIFICATIONS G} <br /> Industrial ._ . T , Cable-Tool 6,a. of Well Excavation ;9i 3rich (n <br /> Domestic/private Drilled�"�. Dia. of Well Casing inch <br /> Domestic/public Driven `" Gauge of Casing Class 160 plastic <br /> Irrigation _ ''Gravel Pack ~. Deptih of Grout Seal 20 ft. <br /> Cathodic Protection *' Rotary <br /> Type of Grout Cement <br /> y <br /> Disposal Other Other Information <br /> Geophysical _ <br />[ Surface Seal Installed 'By <br />� PUMP INSTALLATION: Contractor <br /> E <br /> Type 6f--P ump;;' ,. H.P. <br />[ PUMP REPLACEMENT: /_7 -State Work- Done `- - <br /> PUMP '.REPAIR: %� State Wvrk Dome <br /> DESTRUCTION OF WELL: Well. Diameter f <br /> I Approximate Depth <br /> Desciibe,,Material and Procedure ._ <br /> I hereby agree to 'comply.�wirh_all laws -and-regulations of the San Joaquin Local Health District <br /> .t <br /> and the--State 'of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a neat 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 above <br /> information is true to the,best-of- my.knowledge- acid :belief. I WILL CALL FORA 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> E <br /> SIGNED , x�. , � TITLE. Salesman <br /> PLOT PLAN ON REVERSE SIDE <br /> PHASE i . `FOR DEPARTMENT USE ONLY <br />' APPLICATION' ACCEPTED BY <br /> ADDITIONAL <br /> COMMENTS: <br /> s <br /> PRASE II GROUT INSPECTION """"`' "`` " HA I FINAL INSPECTION- <br />' INSPECTION BY DATE INSPECTION BY DATE .77. <br /> E H 1426 Rev. 1-74 r <br /> /.7 C ou <br />