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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zz_A�� <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 /> JOE ADDRESS/LOCATION 7289 E. Cherokee Lame <br /> CENSUS TRACT <br /> Owner's Name Arthur Turbetti Phone 931 0288 <br /> Address 7289 E. Cherokee Lane City Stockton <br /> Contractor's Name J. A• Thalhamer Co. License # 272 N3 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL /* / DEEPEN / / RECONDITION <br /> Other DESTRUCTION <br /> AL <br /> PUMP INSTLATION REP R / / P REPLACEMENT /-T <br /> /% <br /> DISTANCE TO NEAREST: SEPTIC TANK • SEWER LINEP PRI <br /> - 1 111 <br /> SEWAGE DISPOSAL FIELD S O EEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable T of a. of Well Excavation 1U anc <br /> - Domestic/private D i ia. of Well Casing 6 inc �1 <br /> Domestic/public i e Gauge of Casing log <br /> Irrigation a el a Depth of Grout Seal 5T fl; <br /> Other R t y Typeof rout Cement <br /> O e 0th r formation <br /> PUMP INSTALLATION: Con tact ni er 1 Co. <br /> Type o Pump UubersjtlejH.P. <br /> PUMP REPLACEMENT: / / State Work one <br /> PUMP REPAIR: / / State Work Do e <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 well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRA OT PLAN ON REVERSE SIDE <br /> PHASE I F DEPARTWSNT USE ONLY <br /> APPLICATION ACCEPTED BY I <br /> ADDITIONAL COMMENTS: <br /> PHASE II G U ECTION V P NSP TION <br /> INSPECTION BY TE S CTION DA <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION � J <br /> E H 1426 /72 1M <br />