Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFar0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1, 3 cv <br /> 4 <br /> a 7 <br /> !! THIS PERMIT EXPIRES 1 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 /> r <br /> . t <br /> JOB ADDRESS/LOCATION 15000 Wo Woodbridge Rd. _ _. _ CENSUS TRACT <br /> Owner's Name Be Merlo & Son c/o Joe Meyer Phone 369 20444 <br /> CityLodi <br /> Address _ '' _ 15J0111. Woodbridge Rd. „ <br /> Contractor's Name W. G. Noack Inc. License #,200 794 Phone 466 0696 <br /> V <br /> TYPE OF WORK (Check) : NEW WELL f;7 DEEPEN -/7 -RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION f*f PUMP REPAIR /� PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2�2 ft.SEWER_,L_INES2 0 ft. 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 O <br /> Industrial Cable Tool ._- Dia. of Well Excavation 39--ft. 7 inch <br /> * Domestic/private Drilled Dia. of Well Casing f inch plastic, el� 1� 0 <br /> Domestic/public Driven Gauge of Casing Class 160 <br /> Irrigation Gravel Pack Depth of Grout Seal. 25 ft. <br /> Cathodic Protection * "` Rotary Type of Grout Cement <br /> --Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:___ _ <br /> PUMP INSTALLATION: Contractor W. G. Noack inc. - <br /> Type of Pump Centri ;igal shallow well H.P. <br /> PUMP REPLACEMENT: / / State Work DoneJ ` <br /> PUMP..REPAIR:" /7.--State Work Done - - <br /> ES-TRUCT16N OF WELL: Well Diameter Approximate Depth <br /> `d 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 puttingthe..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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR--DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />} ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> k INSPECTION BY DATE �S' I PECTION BY DATE // -/ =QS_ <br /> kit <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />