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+/ c`�lclurj <br /> !' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE -USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.`� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �1 - 3 <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 2224 Waudmen Ave. <br /> CENSUS TRACT <br /> Owner's Name W J. Striegel 477 7623 <br /> Phone <br /> Address 2223 Waudman Ave. Stockton <br /> City <br /> Contractor's Name J• A• Thalhamer Go. License #272 303 ,Phone 477 1858 ! <br /> TYPE OF WORK (Check) NEW WELL /VT DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT t7 <br /> Od er <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION_S <br /> Industrial -- - -- a <br /> Cable Tool Dia, of Well Excavation - � <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven `� Gauge of Casing • <br /> Irrigation Gravel Pack Depth of Grout Seal one <br /> Other ou <br /> mock we Rotary Type of Grout one , <br /> Other _ OtherInformation <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /77 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 .too fthe best of my knowledge and belief. <br /> SIGNED �YL TITLE <br /> (DRAW PLOT FLAN ON REVERSE SID _ E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ----- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO, INSPECTION PHASE III/FINAL INSPECTION '1 <br /> INSPECTION BY DA INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PR OR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 7/72 1M <br />