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�a SAN JOAQUIN-i;OCALIEALTH 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. <br /> THIS PERMIT `EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ,:7� <br /> licate <br /> Application is hereby made to the San Jo Joaquin Local Health District for a permit to <br /> construct <br /> and/or install the work. herein described. This application is made in compliance with San Joaquin <br /> County Ordinance NO- 1862and the 'Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION <br /> 4 est Rd. CENSUS -TRACT <br /> Owner's Name . ; <br /> M. �'nchell & Sons Phone 462 7863 <br /> Address <br /> E. Main St. City Stockton <br /> Contractor's Name Jo A. Thalhamer Coq <br /> --- License # 272 303 Phone 477 1858 <br /> TYPE OF WORK {Check}: NEW WELL <br /> /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION-/—/ PUMP REPAIR REPLACEMENT /� <br /> Other /% ^" <br /> DISTANCE TO NEAREST': <br /> SEPTIC TANK 100"f't.,SEWER LINES <br /> SEWAGE DISPOSAL FIELD._ PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE- OF WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of Well Excavation 10 inch <br /> Domestic trilled; Dia. of Well Casing 6 •nch <br /> /public Driven" ' "�`�" Gauge of Casing <br /> Irrigation "Gravel Pack <br /> Other Depth of Grout Seal 0 .]09 ---- <br /> . � '�'� Rotary Type of Grout • <br /> Other Other Information, Cement <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump +' <br /> _ ` H;P, <br /> PUMP REPLACEMENT <br /> / / State Work Done / <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter - <br /> Describe Material- Lnd Procedure y _ Approximate-Dep-th'' <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 _re.gulating„well,construction. �Within.FIFTEEN DAYS <br /> n a new well, I will furnish the San Joaquin Local Health District a <br /> after completion of my work o <br /> WELL DRILLERS REPORT of the well and notify thew before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I - FOR DEPARTMENT USE ONLY <br /> APP CATION ACCEPTED L <br /> �• <br /> ADDITIONAL COMMENTS: DATE <br /> P SE II GROUT INSPECTION PHASE II FINAL INSPECT N <br /> INSPECTION BY DATE Z INSPECTION BY <br /> CALL FOR A GR UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. DATE <br /> E H 1426 <br /> 7/72 .1M <br />