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(p SAN JOAQUIN LOCA fMALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel ton AVii. , Stockton, Calif {l <br /> Telephone'. - `(209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. 72-•37S ' <br /> THIS PERMIT EXPIRES 1 -YEAR:FROM DATE 'ISSUED Date Issued -5 L <br /> (Complete In Triplicate) l31 - 330-0/ <br /> Application is:ihereby .madewto 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 andr;the Rules`-and- Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION Core 6tark Rd.'And Inland Drive CENSUS TRACT ' <br /> ;., 464 5729 <br /> Owner's Name'' _' ;�.tr Ted�Del- Carlo,,7 i Phone' <br /> Address <br /> 6717 Stark Rd. City Stockton <br /> _ _ .. ..- ...._ . . <br /> Contractor's Name J• A• Thalhamer Coo License #272 303 Phone 477 1858 <br /> T TYPE OF WORK (Check) : NEW -WELL , / DEEPEN RECONDITION RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT _T <br /> PUMP <br /> Other %J�Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 69 ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I <br /> Industrial Cable Tool Dia. of Well Excavation wbng <br /> C11 <br /> Domestic/private Drilled Dia. of Well Casing L21 inch <br /> �T Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ' Rotary Type of Grout $fav-- Coiue <br /> Other Other Information <br /> l <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well*Diameter Approximate Depth <br /> rDescribe-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 /> informa ion is true to the best of my knowledge and belief. <br /> SIGNED - at ` <br /> TITLE~ <br /> k (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f .".FOR DEPARTMENT USE ONLY . <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> t ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION r:: ' PHASE •III/FINAL INSPECTION <br /> INSPECTION BY '� �, V_ � DATEr3, INSPECTION BY 1p DATE , Jq <br /> G CALL FOR A GROUT INSPECTION pRIOR_TO GROUTING AND .FINAL INSPECTION. <br /> 4/72 IM <br /> E H 1426 <br />