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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> YOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) " 466-6781 <br /> EE�� - iAPPLICATION FOR WELL CONSTRUCTION� OR PUMP PERMIT Permit No. 97 <br /> 1 <br /> ' THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued'�L,3 <br /> (Complete In Triplicate) T <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 /> i County Ordinance-No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W. en`Hiway 4, mile W. of Inland Drive. S. side CENSUS TRACT <br /> Owners Name k,na Vierra &' Sons . ` Phone 463 7801 <br /> Address 4253 Inland Drive City T Holt <br /> Contractor's Name J. A. Thalhamer Co* License #272 303 Phone 77 1858 <br /> TYPE OF WORK (Check) : NEW WELL */ DEEPEN / / RECONDITION /7 DESTRUCTION /? - - <br /> PUMPTAL <br /> yINSLATION /—/ —PUMP REPAIR / / PUMP REPLACEMENT -/� 41 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK • SEWER LINES 136 MPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ={� <br /> _: <br /> . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool-r - Dia, of-Well, Excavation 7 inc Z <br /> Domestic/private Drilled Dia. of Well Casing 3 inc <br /> Domestic/public Driven Gauge of Casing Class. l 0, plastic <br /> Irrigation Gravel Pack Depth of Grout Seal20 ft <br /> d <br /> Other Rotary Type of Grout Cemen <br /> Asparagras washer Other Other Information b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / `State Work Done <br /> PUMP REPAIR: / / 'Stag Work Done ' <br /> k Rxi <br /> ,,DESTRUCTION_OF�.WELL:-! 1kl1 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 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 /> (DRAW PLOT PLAN ON REVERSE SIDE— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTED BY DATE 3 Jc 73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />