Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB4OFFICE 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 l 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7000 S. Inlang Drive CENSUS TRACT <br /> Owner's Name I. N. Robinson Phone 466 7915 <br /> Address 7000 S. Inland Drive City Stockton <br /> Contractor's Name W. G. Noack License # 200794 Phone 948 8817 <br /> TYPE OF WORK (Check): NEW WELL ff DEEPEN -/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR 1-7—PUMP REPLACEMENT /7 O� <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 12 inch <br /> Domestic/private Drilled Dia. of Well Casing 8 inch <br /> Domestic/public Driven Gauge of Casing Class 160, plastic <br /> Irrigation Gravel Pack Depth of Grout Seal z0 ft. <br /> Cathodic Protection - - Rotary Type of Grout Cement <br /> Disposal Other ,_ Other Information <br /> Geophysical Surface Seal Installed By: W. G. Noack <br /> PUMP INSTALLATION: Contractor .. G. Noack <br /> Type of Pump Lineshaft turbine H.P. <br /> PUMP REPLACEMENT: j/7 State Work Done <br /> PUMP .REPAIR: %/ 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 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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ��; � .��' _ a�"i; �,;• TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � DATE ' > <br /> ADDITIONAL COMMENTS: <br /> �`� , <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />