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- 2 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .�. <br /> FOA OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Diattict 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 /> if <br /> .TOB ADDRESS/LOCATION 2 87 Waudmast_ Ave. . CENSUS TRACT <br /> Owner's Name A. R. Hinrichsen, Phone 951 1771 <br /> Address 222 Portola City Stockton <br /> Contractor's Name W. G. Noack Inc* License # 200 794 Phone 466 0696 E <br /> E <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /7;y ' <br /> PUMP INSTALLATION / / PUMP REPAIR -V*_�F PUMP REPLACEMENT- ./7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 65 ft. SEWER LINES 75 ft. PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> .1 i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �V ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS %M <br /> Industrial Cable Tool Dia.• of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 6f— 0 0 <br /> Domestic/public Driven--- - - ­ Gauge of Casing <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 1 hp jet pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Install soundira tube, concrete pedestal, <br /> Chlorinate well. <br /> PUMP REPAIR: State Work Done <br /> ES,TRUCTION OF WELL:' Well Diameter Approximate Depth i <br /> p ; 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-toythe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED G. Noack nco TITLE r <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED f BY DATE <br /> ADDITIONAL. COMMENTS: <br /> T Y PHASE II INS CTI P INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B - DATE 3-2a-7f <br /> E} E H 1426 . Rev. 1-74 ,-7� Im <br />