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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OOSfOFFICE USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. I. <br /> Telephone: (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r 7S 36a� . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,29-.,s <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 r- 35' Morada Lane <br /> CENSUS TRACT ; <br /> Owner's Name 1�elson Nicholson_ Phone 931 2863 <br /> Address - <br /> f�� Morada Lane City Stockton <br /> Contractor's Name fid.- G._Noack Inc._-. . -\---License 4-20o7_94- Phone-•466.0696- <br /> t <br /> TYPE OF WORK (Check): NEW WELL%T DEEPEN/� RECONDITION 0**�j DESTRUCTION f7 <br /> PUMP INSTALLATION <br /> /—/ PUMP REPAIR /-7-pump REPLACEMENT • ' <br /> Other !/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK 72_ft, SEWER LINES 82 ft. PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool Dia. of Well Excavation 8 q inch <br /> I * Domestic/private: I Drilled Dia, of Well Casing inch <br /> Domestic/public t Driven Gauge of Casing .10 <br />! r�` Irrigation Gravel Pack Depth of Grout Seal None <br /> Cathodic Protection t�***--- Rotary; Type of Grout <br /> EDisposal 7. . Other, Other Information <br /> r Geophysical ., _ {`Falk � Surface Seal Installed B <br />{f PUMP INSTALLATION: Contractor Id. G. Noack Inc.- <br /> '-Type-"of Pump Fairbanks Morse submir-bible-._- H.P. I. <br /> PUMP REPLACEMENT: / / : State Work Done full um and install in rebased well <br /> PUMP .REPAIR: / / State Work Done <br /> ESTRUCTION 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 anew well.,-.j 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 TOj GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY - <br /> f PHASE I � r <br /> APPLICATION ACCEPTED BY DATE r S <br /> ADDITIONAL COMMENTS: E - <br /> PHASE II GROUTIINSFECTION PHA II F INSPECTI N <br /> INSPECTION BY ' '.'INSPECTION <br /> DATE <br /> x_74.. M <br /> -E H 1426 Rev. 1-74 ; <br />