Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS--:ZL_111 . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? js- <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 5015 Foppiano Lane CENSUS TRACT <br /> Owner°s Name Andy Laird Phone L-1- 0574 <br /> Address l Fo iano Lane City Stockton <br /> Contractor's ,Name W. G. Noack Inc, -.Licensee-#-200 744 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /7 RECONDITION /7 DESTRUCTION /7 . <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK16b ft. SEWER LINES '= PIT PRIVY <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC-WELL,`G - -PUBLIC DOMESTIC WELL: ' u <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 /> Cathodic Protection Rotary Type of Grout - <br /> DisposalOther Other Information <br /> EGeophysical:... ' _ Surface Seal Installed, By, -- - <br /> IINSTALLATIONt Contractor W. G. Noack Inca ' <br /> Type of Pump Berkele , turbine H.P. <br /> jP2 REPLACEMENT: / / .State Work Done , <br /> PUMP '.REPAIR: 177 State Work Done Acid 20 ft. _of colo=,. -and shafting. <br /> ES-TRUCTION OF WELL: Well Diameter t 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, 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-beat of my knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR T GROUTING D A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1kIL4ZN4 INSPECTI <br /> INSPECTION BY :- DATE INSPECTION BY DATE <br /> `1:. - E H 1426 -Rev. 3-74 . . 1-74 2ht <br />