Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72— <br /> THIS <br /> ZTHIS 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 /> JOB ADDRESS/LOCATION 3620 Wilmarth Rd, CENSUS TRACT <br /> Owner's Name " James Jo. Johnson Phone 931 2388 <br /> Address 3620 Wilmarth Rd* - - City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL AW DEEPEN /% RECONDITION /_7 DESTRUCTION /_ ' <br /> PUMP INSTALLATION / / PUMP .REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: "SEPTIC TANK70 FE. SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPACE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation 10 inch w i <br /> :Domestic/private Drilled Dia. of Well Casing inch <br /> Domestic/public Driven Gauge of Casing .109 C <br /> Irrigation Gravel Pack -.Depth of Grout Seal 50 ft. G <br /> Other -- r/ Rotary Type of Grout Cement i <br /> - _ Other Other Information <br /> PUMP INSTALLATION: Contractor Universal Pump Co. j <br /> Type of Pump Jacuzzi submersible H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done ' <br /> ESTRUCTION OF WELL: Well Diameter OVmers responsibility Approximate Depth <br /> Describe Material and Procedure j <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 putti'rig the well in' use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED B C� DATE �CJ f(1 �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IMytiALANSPECTION <br /> INSPECTION BY DATE INSPECTION BY D TE //— <br /> CALL FOR A GROUT INSPECTION_PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 7/72 1M <br />