Laserfiche WebLink
SAN JOAQUIN LOGAL.. 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 <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. 1862' and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4845 Beer Creek Rd. CENSUS TRACTS�j <br /> Owner's Name Harold Van Arndale Phone 368 17+3 <br /> Address 4845 Bear Creek Rd* City Lodi <br /> Contractor's Name J. A* Thalhamer Coe License #272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL /„/ DEEPEN / / RECONDITION /_-7 DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /-7 r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK =ft. SEWER LINES 70 ft. 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 10 inc -� <br /> Domestic/private Drilled Dia. of Well Casing Ync 001 <br /> Domestic/public Driven Gauge of Casing '; <br /> Irrigation Gravel Pack -Depth of Grout Seal 50ft <br /> 0 <br /> Other "— Rotary Type of Grout Cement <br /> Other Other Information <br /> F <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of >Pump $ H,.-P,.- <br /> PUMP REPLACEMENT- / / State Work Done <br /> PUMP REPAIR- /% State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure i <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 /> t:WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> , informat n is true to the best of my knowledge and belief. - x , <br /> E SIGNED ! �-ii-1' Q TITLED` ,,tj 7 T <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED,.BY '' DATE <br /> ADD ITIONAL`'COMMENTS <br /> PHASE J1 GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE , Y�'-70 INSPECTION BY DATE - -? <br /> F CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Ott*-- <br /> E H 1426 7/72 IM <br /> A <br />