Laserfiche WebLink
Si.W JOAQUIN LOCAL 1:EALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--G 783" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z, 5-Z, 1, <br /> 1 6 <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 8958 Live Oak Rd. CENSUS TRACT <br /> Owner's Name Leo Suttonr. Phone .931 1628 <br /> Address 895B. Live Oak Rd. City Stockton <br /> Contractor's Name J. A. Tha.lhamer Co. License 41272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL JM*/ DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTLATION 1�*/ PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 140 ft-SEWER LINES 140 ft-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing PP• <br /> ' Domestic/public Driven Gauge of Casing 10 <br /> ** Irrigation Gravel Pack Depth of Grout Seal None 00 <br /> Other Rotary Type of Grout _ <br /> Other Other Information s <br /> ,F <br /> PUMP INSTALLATION: Contractor J. A. Thalhamer Co. <br /> Type of Pump Barnes submersible H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well 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 /> SIGNED TITLE <br /> (DRAW .PIOT PLAN ON REVERSE SIDE) <br /> F DEPARTMEN <br /> PHASE I <br /> APPLICATION ACCEPTED B CE ONLY DATE S L <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / -,9 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />