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¢ SAN JOAQUIN LOCAL 11EAL'TH DISTRICT <br /> FOR OFFICE USE: -1601 E. Hazelton Ave.",' Stockton, Calif. <br /> Telephone i :1 209) 46'5-6-781 <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No.7?- Gam(, 7 <br /> _ ?ileq <br /> THIS 'PERMIT,EXPIRES l-,YEAR' FRON DATE ISSUED .:• :'':._Date Issued. '7 — -7Y <br /> (,Complete -In' Triplicate) <br /> Applicatio' A8,herebyfmaderto the.,San;Joaquin;-Local Health District for a .permit to construct <br /> and/or install the work herein described. This application, is made iri compliance with San Joaquin <br /> County Ordina'nc&• No.•-18b2,,aiidrthe •Rules.�and Regulations'- of the San. Joaquin Local Health District-. <br /> - �°:i.'•°1s. � ,,,"?r) ;'".ri ��i r ",..Si:�+'S. 8#1•. a:s7 .�;3.. � f'.',i::2; a <br /> JOB ADDRESS/LOCATION J 430 Watters'Rd. CENSUS TRACT- <br /> Owner's-'Nameax ' ;kr.s0 Sibyl ,Hall-v •rj Phone 982 15$5 <br /> Address J 430 Watters Rd. City French Camp <br /> i Contractors Name J. A. ThY alhemer Co*, Licepse f972 303 Phone 477 1858 <br /> k <br /> rTYPE OF WORK (Check) : NEW WELL -fWf DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION '/ I PUMP REPAIR / / PUMP REPLACEMENT <br /> kI. Other-./ ./._. <br />{ DISTANCE TO NEAREST: SEPTIC TANK 70 -Lot-SEWER LINES 60 ft-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f. <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPEC I ATJON <br />€ Industrial i Cable Tool Dia. of Well Excavation r <br /> Domestic/private 1 Drilled Dia. of Well Casing _ , inch <br /> E Domestic/public � " t Driven" -Gauge of Casing -.109 <br /> i Irrigation # Gravel Pack Depth of. Grout Seal 50 ft. <br />` Other l wX__ Rotary 'Type of Grout ' Cement <br /> 1 Other Other Information ' <br /> PUMP INSTALLATION: <br /> Contractor J. A. Thalhsmer Co. <br /> Type o£ Pump Move 'et pump to new well H.P. <br /> PUMP REPLACEMENT: S tate-Work-Done <br /> PUMP REPAIR: / / State Work Done <br /> f <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 01 <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 iwell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> w. <br /> SIGNED <br /> ` r �° � # �� TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DE ARTMENT USE ONLY <br /> .PHASE I (A,APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PH,OE Ij GR T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY ,�9 DATE <br /> E. <br /> CALL FOR A_GROUT,INSPECTION PRIOR TO- GROUTING AND FINAL INSPECTION. <br /> E H 1 6 �� Co �, 4/72 1M <br />