Laserfiche WebLink
o <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ya <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT; " ' ' Perinit `No,. _2a,7,d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 04CENSUS TRACT <br /> Owner's Name Conrad Silva Phone 463 8004 <br /> Address 1431 W. Walnut St. City Stockton _ <br /> Contractor's Name J. A. Thalhamer Co. License # 27- 2 303 Phone 477 1W�_ <br /> TYPE OF WORK (Check) : NEW WELL A DEEPEN / j RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 92'z t. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7 inch y�y <br /> Domestic/private Drilled Dia. of Well Casing 2--_ inch _ -P <br /> Domestic/public Driven Gauge of Casing Class 160, plastic <br /> Irrigation Gravel Pack Depth of Grout Seal 30 ft, <br /> Other ** Rotary Type of Grout Cement <br /> Labor campOther Other Information <br /> �T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done Q <br /> PUMP REPAIR: <br /> / / State Work Done <br /> ,ESTRUCTION 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 /> SIGNEDrfwZ TITLE`I <br /> ,4t— <br /> (DRAW PLOT PLAN ON REVERSE SIDET <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 1S ) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - r DATE <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 7/72 1M ,'' <br />