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hw L 0 AOL I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --f-06,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ti <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Regltfi District for a permit to construct s <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 5400 S. Maybeck Rd*- CENSUS TRACT <br /> Owner's Name Lawrence Dal Soldsto Phone 462 7901 <br /> Address 5400 S. Maybeck Rd. City Stockton <br /> Contractor's Name A, G. Noack Inc. License # 200 794 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN 17 RECONDITION DESTRUCTION /"7 <br /> PUMP INSTALLATION /.'/ PUMP REPAIR /_7 PUMP REPLACEMENT 7 <br /> Other /_7 QJ� <br /> DISTANCE TO NEAREST: SEPTIC TANK 256 ft. SEWER LINES PIT PRIVY _ t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' ' PUBLIC DOMESTIC WELL C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Zable Tool r Dia. of Well Excavation 6 inch. <br /> * Domestic/private Drilled Dia. of Well Casing 2' inch plastic <br /> Domestic/public Driven Gauge of'Casing Class 164 ' <br /> Irrigation Gravel, Pack Depth of `Grout Seal 20 ft. . <br /> Cathodic Protection Rotary,---- - Type. of Grout Cement 75 <br /> Disposal Other t Other Information <br /> Geophysical Surface Seal Installed By,: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> { <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPIREPAIR: /_7 State Work Done _ <br /> ES;TRUCTION OF WELL: Weil Diameter Approximate Depth f i <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 W. G. Noack by U, ,.L✓... "ti, TiTL L� <br /> ----- -(DRAW•PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DA L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I F INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE L <br /> µE H 1426 Rev. 3.--74 �.-v <br /> ;. . 1-7 4 2M <br />