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SAN JOAQUIN LOCAL UALTH DISTRICT <br /> OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> FOR Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No &-/.zeL <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued 2 4z-Zo <br /> i (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 /> s and Regulations of the San Joaquin Lacal.Health District: <br /> County Ordinance No. 1862 and the Rule <br /> C NSUS TRACT <br /> JOB ADDRESS/LOCATION 376 Ponderosa St. <br /> . 982 481 <br /> Owner's Name <br /> Rose Ellis Phone <br /> French Camp <br /> t 310 7th Street City `1 <br /> Address <br /> 272 303 477 1858 <br /> Contractor's Name J. A. Ihlhazner Co. License # Phone <br /> TYPE OF WORK (Check): .',,, NEW WELL I*7 DEEPEN 1-T RECONDITION /�/ DESTRUCTION /`7 <br /> " PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> E DISTANCE TO NEAREST: 'SEPTIC TANK t. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ; r CONSTRUCTION SPECIFICATIONS <br /> ` <br /> Industrial Cable Tool Dia. of Well Excavation lO inch <br /> * Domestic/private Drilled Dia. of Well Casing 6 inch <br /> Domestic/public, Driven Gauge of Casing pl0 <br /> Irrigation <br /> i� Gravel Pack �- -Depth of Grout Seal ft. Ins <br /> Other I! * Rotary Type of Grout Cement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor )weer •F ' ` � <br /> n Type of Pump Jet !pimp H.P. Tp <br /> f, d F � •a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done t <br /> I <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 <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. y- <br /> SIGNED 144 <br /> TITLE .r.�e <br /> r (DRAW PLDT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '' `I <br /> APPLICATION ACCEPTED,BY ��� Y DATE <br /> ADDITIONAL COMMENTS: 6 <br /> PHASE II GROUT INSPECTION PHASE XI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f/�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />