Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 73 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <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 1205 Paloma CENSUS TRACT <br /> Owner's Name John M. Stevens Phone 498 5434 <br /> Address 1205 Paloma City Stockton <br /> Contractor's Name J, A. Thalhamer Co. License 1?72 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL AV DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> AL <br /> PUMP INSTALLATION kw/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 74-ft- 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 Excavationano .... <br /> Domestic/private Drilled Dia, of Well Casing inch <br /> Domestic/public Driven Gauge of Casing .109 O <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. plus N� <br /> Other — Rotary Type of Grout Cement <br /> Other Other Information +Q <br /> A <br /> PUMP INSTALLATION. <br /> Contractor J. A. Thalhamer Co. <br /> Type of Pump Berkeley 'et pump H.P, <br /> PUMP REPLACEMENT: / / State Work Done Pull pump from old well and install in new well. <br /> PUMP REPAIR: / / State Work Done <br /> E� STRUCTION OF WELL: Well Diameter 6 inch Approximate Depth 72 ft- <br /> Describe Material and Procedure Cement -grout only <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 /> . C ' <br /> SIGNED ° TITLE <br /> V441-le'Ln..2 A <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FQR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS: cl.� <br /> PHA E II GROU INSPECTION PHA III/FINAL NSPECTION <br /> INSPECTION BY ATE INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />