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SAN JOAQUIN LOCAL I{EALTH DISTRICT <br /> FOR OFFICE JUSE: 1601 E. Hazel toh'.:Av6•::, Stockton, Calif. <br /> Telephorne:.,: (209):4`66"6781 <br /> APPLICATION FOR WELL�CONSTRUCTION OR PUMP PERMIT Permit No. 7L-9 7 0 <br /> THIS PERMIT. EXPIRES I YEAIt': FROM .DATE; ISSUED Date Issued <br /> -(Complete In. Tiriplicate) <br /> Applicatioh�is �herebys.madeT-.t. the-San jJoaquin' Local Health District'• for a permit to construct <br /> and/or install the work herein described. This"application. is' made incompliance with San Joaquin , <br /> County,.Qrdinance.No.:.1862 and,.the,Rule's `arid,A-Regulations,of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION 13712 De Vries Rd. <br /> CENSUS TRACT <br /> Owner's_ Natrie..f 1-i <br /> Phone 369 5546 <br /> Address <br /> .- .-.. Boat 151 � <br /> City . <br /> C' Hilt, Calif. <br /> Contractor's Name J. A. ihalhamer Co. License 4272 303 Phone477 1858 <br /> TYPE OF WORK (Check) : NEW WELL 0/ DEEPEN 7/�/ 'RECONDITION /� pESTTtUCTION /� <br /> PUMP INSTALLATION /_/ PUMP REPAIR/ / PUMP REPLACEMENT /_7 - <br /> Other' / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 92 Pt. SEWER LINES 9 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,J <br /> 5 <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 10 inoh <br /> Domestic/private Drilled Dia, of Well Casing 6 inch <br /> Domestic/public Driven Gauge of Casing .109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other Rotary Type of Grout Cement C <br /> Other Other'Information <br /> PUMP INSTALLATION: Contractor Owner to install own pump <br /> Type of Pump Barnes submersible <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> � � k <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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I .FOR DEPARTMENT USE ONLY { <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION $Y DATE r INSPECTION BY DATE o1 <br /> CALL FOR A GROUT .INSPECTION PRIOR..TO GROUTING AND FINAL INSPECTION. T <br /> E H 1426 '... f <br /> 4/72 1M <br />