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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave''"'Stockton, Calif. <br /> Telephone:.'. -(2-09)'.466- 6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT-EXPIRES 1: YEAR:FROM' DATE 'ISSUED Date Issued 7v <br /> ' 1 (Complete Tni;Triplicate) �(`q4 <br /> Applicatioft5is,herebyimadeito .the`�5an Joaquin,.Local Health District' for a fin' Wtan <br /> uct <br /> and/or install 'the work herein described. This application is made. in com i Joa uin'pp �! <br /> County-,Ordinance7No. 1862.and,�the.�RulesF7and'.�Regulatibris of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION y 17222 Cal_ Drive . _ _ CENSUS TRACT'' <br /> ."•r�-n#{:it -y� -'fTi�,.d ;S i; '$'} fx'_3ii-.�� S`� I:-) � : ' ^! .�e - ' - - <br /> Owner's °Name' , .. ,,Loryl,Miller. :y t r ;;.. �_7 Phone 369 8151 <br /> Address 17252 Cal Drive F City Lodi <br /> Contractor's Name J. A. Thalhamer Co. License #272 503 Phone 477 1853 <br /> f TYPE OF WORK (Check) : NEW WELL / / DEEPEN /tea/ RECONDITION DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other / / -- <br /> I ° <br /> DISTANCE TO NEAREST: SEPTIC TANK �70 ft.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT. OTHER <br />� i r <br /> INTENDED USE t TYPE OF WELL " �" CONSTRUCTIONsSPECTFTCATTONS J <br /> ` Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private: Drilled Dia. of Well Casing inch <br /> Domestic/public Driven Gauge of Casing. .109 i <br /> Irrigationq Gravel..Pack Depth of Grout .Seal <br /> Other Rotary Type of Grout, <br /> Other Other-.Information ,. <br /> A. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump E' _..�_ ..H'.P <br /> PUMP REPLACEMENT: /_7 State Work Done # • <br /> F 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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the welland notify -them before putting the well in use. The-above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED t Lv`j`^�`� TITLE A � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY v DATE ( "� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION , PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY eZ? DATE - L <br /> CALL F'OR A GROUT INSPECTION. PRIOR, TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />