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SAN JOAQUIN 6"dA HEALTH DISTRICT <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. 73-35`;9'Crd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z::Z�73 <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 S. W. C -r. Alhambra and Hildreth Lane CENSUS TRACT <br /> Owner's Name Ed. Vernengo Phone 477 6983 <br /> Address 4903 Tanglewood Lane City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License #272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL f*7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK li&tSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �ft- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation I0M <br /> -i" 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 <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor Moorman 'r°ater Systems <br /> Type of Pump hp Barnes submersible H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 ,,� v. TITLE. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� � F���i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE T GR UT INSPECT PHASE III F BYAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GR INSPECTION PRAR 0 GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 <br />