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r f <br /> *01111, SAN JOAQUIP LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; ;Z'1601 E. Hazelton Ave. , Stockton, W-Pq <br /> a Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13-156 oj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.-1.1 -73 <br /> (Complete In Triplicate) <br /> Application is hereby madeT'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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 10685 Hildreth Lane <br /> CENSUS TRACT <br /> Owner's Name Don-O. Dyer Phone 478 6944 <br /> Address P.O. Box 8887 City Stockton <br /> Contractor's Name J. A. Thalhamer Coo License 1972 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL,` /W/ :DEEPtN./_7 RECOND€T€ONS/-7 DESTRUCTION Jam <br /> PUMP,..INSTA_LLATION.,/ / 'PUMP <br /> REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -"J"'" SEWER LINES PIT PRIVY ,... <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ♦�., <br /> i <br /> - INTENDED USE {TYPE OF WELL--- ' �W �Q <br /> i+ __. CONSTRUCTION SPECIFICATIONS VV11 <br /> Industrial Cable Tool Dia. of Well Excavation 107 inc <br /> *' Domestic/private Ak Drilled Dia. of Well. Casing 6 inc <br /> Domestic/publici Driven Gauge of Casing 9 <br /> _ Irrigation Gravel Pack Depth of Grout Seal 50 Pt. L <br /> Other — Rotary Type -of Grout Cemen <br /> `. Other Other,Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State Work- hone <br /> PUMP REPAIR; / j State Work" Done -- + <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i, 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 a <br /> , WELL DRILLERS REPORT of the well and notify them before ting the well in use. The above <br /> I informs on is true to the best of my knowledge and bel def, <br /> I SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ,. -"� <br /> A FOR DEPARTMENT USE ONLY -' <br /> PHASE I <br /> r d <br /> APPLICATION ACCEPTED BY } DATE <br /> ADDITIONAL COMMENTS: ! <br /> ---°'PHASE''Ik,GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION. BY DATE 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4� <br /> E H 14261 <br /> 7/72 1M <br />