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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto.,, Calif. <br /> ; ? Telephone: ' (209) 466-6781 <br /> 11 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z- 6 S/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,3- - <br /> t <br /> (Complete In Triplicate) ow--0 <br /> Application is hereby made to the San' Joaquin Local Health District for a pe�it to construct 0 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin PI <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. r. <br /> JOB ADDRESS/LOCATIONcp=Er. HWYEE S�RAC' <br /> Owner's Name Aijq1iEjf1 R GnMAS Phone-5, <br /> 526 gest Cliff Dr. ��� <br /> Address _ CitySanta. Cruz, Calif <br /> Contractor's Name )alter G. Noack & Son, Inc. License # 2DD794 Phone ' 466.-0696 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /X/ PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal- - - --- - - - <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP' INSTALLATION: Contractor falter G. Noack & Son, Inc. <br /> Type of Pump 1 12 _HP Gorden jet Pump H.P. <br /> PUMP REPLACEMENT: / / 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 he be t of my knowledge and belief. <br /> i <br /> SIGNED TITLE ❑ffi r,r C1 Prk i e: <br /> (DRAW PWT PLAN ON REVERSE SIDE) r <br /> F R DEPARTMENT USE ONLY <br /> PHASE I y <br /> /Z <br /> APPLICATION ACCEPTED B r cl,� DATEd Z72 . <br /> ADDITIONAL COMMENTS: 1 <br /> Je <br /> PHASE _II GROUT INSPECTION PHA III/FINAV INS ECTION <br /> INSPECTION BY' -- - DATE INSPECTION BYE -7: Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />