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,;;_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR :WELL CONSTRUCTION OR PUMP PERMIT Permit No. -2 /y�-// <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby Evade 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. 1562 and the. Roles and Regulations of the San Joaquin Local Health District. <br /> 11' 50 West Ei ht Mile Rd. yfF "tT r <br /> JOB ADDRESS/LOCATION E CENSUS TRACT <br /> Owner's Name Mrs. S. Rocha Phone 477 1436 <br /> Address 8949 Davis Rde City . Stockton; ' <br /> Contractor's Name J. A. Thalhamer Coo License #272 303 Phone 477 1858 <br /> i <br /> I _ <br /> TYPE OF WORK (Check) : NEW WELL _W DEEPEN / J RECONDITION /_7 DESTRUCTION /_ } <br /> PUMP i'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK 72 t--SEWER LINES V Tt-PITPRIVY ' <br /> i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER " <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation 10 inc <br /> Domestic/private Drilled _Dia. of Well Casing 3 incE plastic <br /> Domestic/public Driven � n Gauge of Casing Sc edu r IM �. <br /> Irrigation Gravel-• Pack Depth of Grout Seal 30 ft. <br /> Other Rotary Type of Grout _ Cement <br /> Other Other Information Well screen on bottom <br /> r <br /> PUMP INSTALLATION: tontriilactor Delta Pump Co. <br />� Type of Pump Shallow VreI1---__ _-- � ..- - -- -- .•-._..,__._ R.P..P. <br /> H1 <br /> PUMP REPLACEMENT: / / "State Work Done 9 <br /> PUMP REPAIR: / / State Work Done <br /> �r <br />'.DESTRUCTION OF WELL: Well Diameter 6 inch Approximate Depth Unknown <br /> Owners responsibility 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 /> (DRAW PLOT PLAN ON. REVERSE SIDE <br /> v.. FO RTMENT USE ONLY <br /> ' PHASE I •. _ <br /> APPLICATION ACCEPTED B (� DATE Z. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE 0 . <br /> E H 1426 7/72 1M <br />