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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Y ,1601 E. <br /> Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> { Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cos <br /> and/or install the work herein described. This application <br /> County Ordinance No. construct <br /> 1852 and the Rules and Regulationsofthe SaneJoaquinpLocaleHealthwith SDistrict.an n <br /> .70B ADDRESS/LOCATION 17398 S. 'racy Blvd. <br /> District. <br /> CENSUS TRACT <br /> Owner's Name Airs. Louise Galli <br /> Phone 835 1173 <br /> Address 17398 S. Tracy Hlvds <br /> City Tracy <br /> Contractor's Name J• A• T halhamer Co. <br /> License # 2723 3 Phone 477 1858 <br /> TYPE OF--WORK= (Check)-:--NEW WELD/ / DEEPENS/_� <br /> _ / RECONDITION'L.7—-DESTRUCT16N-/7— ---- <br /> PUMP INSTALLATION _/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> 'Other �/ / -� /-' <br /> DISTANCE TO NEAREST: SEPTIC TANK - <br /> SEWER LINES PIT PRIVY <br /> +SEWAGE ZSPOSAL FIELD �_,t CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial E T Cable Tool <br /> Domestic/private Dia. of Well Excavation inc <br /> Domestic Drilled _Dia. of Well Casing 3 <br /> /Public Driven Gauge of Casing C ass <br /> Irrigation i Gravel Pack \ <br /> Other -- -- Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information Original well dep'h 177 ft. <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of� Pump - Jacuzzi shallow well <br /> _ H.P. I <br /> PUMP REPLACEMENT: / / State Work <br /> PUMP REPAIR: <br /> / / State Work Dane <br /> ESTRi7GTION OF WELL: Well Dia' terf <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply withall Yaws and regulations of the San Joaquin Local Heal <br /> and the State of California pertaining to or regulating well construction. th District , <br /> IFTEEN AYS .,, <br /> sfter completion of my work onoa`new well, I will furnish the San Joaquin LocalhHealth District a <br />+TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformatiori is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> CHASE I FOR DEPARTMENT USE ONLY <br /> FTLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE ff <br /> PHASE' <br /> II GROUT INSPECTION PHASE III FINAL INSPTI <br /> ECON <br /> NSPECTION BY DATE INSPECTION BY <br /> .CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. DATE a_ y <br /> E H 1426 <br /> 7/72 IM C ri­�5 i <br />