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-ja SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUM?' PERMIT Permit No,Z2, <br /> k <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 Tracy Island Rd. .Klein. Ranch CENSUS TRACT <br /> Owner's Name Ed. Gamel Phone None <br /> Address Tracy Island Rd* Union Island, Klein Bros. ranch City Stockton <br /> Contractor's Name J. A. Thalhamer Coo License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL /„/ DEEPEN / / RECONDITION /_7 DESTRUCTION /7 1 <br /> PUMP INSTALLATION: / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 60 . SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD 70 ft- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation inc <br /> Domestic/private Drilled Dia. of Well Casing 3 inc - i <br /> Domestic/public Driven-' Gauge of Casing Plastic # 160 <br /> Irrigation Gravel-. Pack=- Depth of Grout Seal Not known as ye r <br /> Other Rotary Type of Grout Cement <br /> Other Other Information _ #� <br /> PUMP INSTALLATION: Contractor J. 'A. Thal_hamer Co. ' <br /> f Type of Pump Jacuzzi shallow well pump H.P. <br /> PUMP REPLACEMENT: d_ � �- <br /> / / State Work Done <br /> PUMP REPAIR: / / State Work Done , <br /> r <br /> PESTRUCTION WELL:: Well Diameter <br /> - -- „ .,....._., Approximate Depth <br /> Nohe 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-toyor.-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 /> SIGNED ., ,� -_ ..r _ -. . . _. ., ._�. ' 'TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I !! 7 <br /> APPLICATION ACCEPTED BY DATE /f <br /> ADDITIONAL COMMENTS: <br />! PHASE II GROUT INSPECTION PHASE II / INAL INSPECTION <br /> ` INSPECTION BY ATE j INSPECTION BY DATE l 2 �tz Z221-1 <br /> i <br /> CALL FOR A, GROUT INSPE ION PRIOR TO GROUTING AND FINAL INSPECTION. 10 <br /> E H 1426 f $ 7/72 1M <br />