Laserfiche WebLink
''"SAN JOAQUIN LOCAL HEALTH DISTRICT `�7 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.���&-' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Xssued/k3r? <br /> Application is hereby made to thefSan (Joaquin Local Complete In rHealth District for <br /> and/or install the work herein described. This application is made in compliance twithnct Sanu3aaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Lot No. 23 Free Rd . z mile 19. of Hiway 12 <br /> CENSUS TRACT <br /> Owner's Name Robert De Bard 368 4018 <br /> Phone <br /> Address 1809 W. Vine Ste Lodi <br /> City <br /> Contractor's Name J. A. Thalhamer Coo License # 272 303 x+77 1$58 ' <br /> Phone <br /> TYPE OF WORK (Check).: -NEW-WELL V, _DEEP&—/ / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT /- <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> Nene SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT ICA IONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin 6 5 <br /> Domestic/public Driven g <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ft. <br /> - Other _ _ Rotar <br /> y Type of Grout Cement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump Su m,r si Le � <br /> H.P. <br /> PUMP REPLACEMENT- /7 State'Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 r <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE X241 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> kPPLICATION ACCEPTED BY / DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ENSPECTION BY DATE INSPECTION BY -DATEy- 7 <br /> -_ ,r, <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . <br /> 7/72 1M <br />