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SAN JOAQUIN LOCAL 11EALTt3 'DISTRICTey . <br /> ,Stb).kton, <br /> FOR OFFICE USE: 1601 L. Hapeone:-tee.�,... <br /> Telephone;•. .- {209} 466-6781 PENT Permit No. <br /> LIGATION FOR IW"L*,,CONSTRUCTION OR Pi1MP <br /> �V Date Issued _1�_-�—�v <br /> THIS PERMIT -EXPIRES I:YEAR',IROM DATE ISSUED + <br /> (Complete In Triplicate} , ermit to Construct <br /> is 'a licatiou is-lade in compliance walthith SDistrict.an n <br /> A lication' is he work <br /> the�Sa��edaquTh`-L°cpp Health District for;tia p Local He <br /> PP Joa uin <br /> and/or install the work herein described. <br /> 1. �> <br /> County .Ordinance-No. '1862 .and. the Rules;and%•Regulations of the .CENSUS TRACT <br /> j I,, :.. , . . , <br /> DRESS/LOCA167 Hive A <br /> JOB AD TION Phone x+63 7079 <br /> *T j, <br /> Owner's_Name : Oho Pelle rid^,= City Stockton. <br /> 167 Hiwe 4477 1858 <br /> Address . <br /> �Q.. .. _ License # 272 303 Phone ' <br />} Contractor's Name <br /> j, )L. Thalhamer Co.. <br /> ~ <br /> RECONDITION /�I DESTRUCTION /? <br /> NEW WELL `I . DEEPEN I I PUMP REPLACEMENT I� <br /> f TYPE OF WORK (Check) : PUMP INSTALLATION / I PUMP REPAIR ISI i '. <br /> i Other / / new well onl r � .: <br /> ft—.`SEWER'LINES 79 -ft:PIT-PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK'9 CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELDemu <br /> 4 CONSTRUCTION STECIFIlATIONS <br /> TYPE OF WELLIenc <br /> tj <br /> INTENDED USE Cable Tool Dia. of Well Excavation Lnc <br /> Industrial Drilled Dia, of Well Casing lactic <br /> M * Domestic/private �_ Gauge of Casing Olass 200, p <br /> Driven <br /> Domestic/public <br /> Gravel-Pack� -Depth of Grout Seal 20 �t ...� <br /> Irrigation RotaryType of Grout Neat cement <br /> Other Other 'Information <br /> t Other _. <br /> k r w <br /> PUMP INSTALLATION: Contractor H.P. <br /> l Type of Pump '. 4 <br /> PUMP REPLACEMENT: / State'Work.Done' <br /> PUM£' REPAIR: / / State Work Done" l <br /> o Approximate Depth <br /> f .DESTRUCTION OF WELL: Well eter <br /> DescribeMaterialand Procedure <br /> 1 t <br /> San Joaquin <br /> cal <br /> lth <br /> rict <br /> II hereby agree to comply with all laws and reglns owel ecan truction.LoWithinaFIFTEEN tDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distr ct <br /> befor <br /> WELL DRILLERS REPORT of the well anlief. <br /> d notify them e putting the well in use. The above <br /> information is true to the best of my knowledge and be <br /> TITLE <br /> SIGNED d, 6" (DRp,W PLOT PLAN ON REVERSE SIDE) <br /> a FQR DEPARTMENT USE ONLY r <br /> PHASE I <br /> DATE 7/ � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION Z <br /> PHASE II GROUT INSPECTION INSPECTION (A) Vo DATE / 7 <br /> INSPECTION BY V DATE <br /> CALL F'OR A GROUT.INSPECTION„PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 IM <br /> E H 1426 <br />