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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� O FICE"USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 719- 7- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Id-7,1— <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11ealth 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 9052 E. Live Oak Rd. CENSUS TRACT <br /> Owner's Name Cotto assi Farms Phone 948 4022 <br /> Address 11292 N. Alpine Rd. City , Stockt-on <br /> Contractor's Name W. G. Noack Inc. 4 <br /> License # ,200794 Phone -948- 8$17 <br /> TYPE OF WORK (Check); NEW WELL/7 DEEPEN 'j1*7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/_/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK142 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 Wall Ekdavation 8 inch <br /> t <br /> * Domestic/private Drilled Dia. of Well Casing _ b inch--- <br /> Domestic/public __...___ Driven Gauge of Casing log , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor W. G. Noack Inc* <br /> Type of Pump Fairbanks 14orse sub* H.P. <br /> PUMP REPLACEMENT: , j/ / State Work Done Pulled pump so well could be. deepened end <br /> _ will reinstall pump when we is repaTmzl <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--putti ig-the..weli. 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 GROUTING OND A FINAL INSPECTION. <br /> SIGNED V TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> "- <br /> APPLICATION' ACCEPTED BY DATE , ��l'�b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74G "' '/' h/75 2M <br />