Laserfiche WebLink
SAN JOAQUIN LOCAL 17EALTH 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. 7z, 5-7, <br />9556 <br />THIS PERMIT EXPIRES I'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 />i <br />JOB ADDRESS/LOCATION 8958 Live Oak Rd. CENSUS TRACT <br />Owner's Nasse Leo Sutton, Phone 931 1628 <br />Address 8958 Live Oak Rd. City Stockton <br />Contractor's Name J. A. Thalhamer Co. License X1272 303 Phone 477 1858 <br />TYPE OF WORK (Check): NEW WELL /M*J DEEPEN'/ / RECONDITION / / DESTRUCTION /-% <br />PUMP INSTALLATION 1*/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br />Other /—/ T <br />DISTANCE TO NEAREST: SEPTIC TANK 140 :ft -SEWER LINES 140 It -PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />INTENDED USE TYPE OF WELL <br />inaustriai <br />Domestic/private <br />Domestic/public <br />t* Irrigation <br />Other <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />�+ Rotary <br />Other <br />CONSTRUCTION SPECIFFCATIONS <br />Dia. of Well Excavation <br />Dia, of Well Casing pp. <br />Gauge of Casing <br />Depth of Grout Seal None 00 <br />Type of Grout {� <br />Other Information <br />Contractor J. A. Ahalhamer Co. _ <br />Type of Pump Barnes submersible H.P. <br />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 <br />PHASE I <br />APPLICATION ACCEPTED <br />ADDITIONAL CODIMENTS : <br />PHASE II <br />INSPECTION BY <br />TITLE <br />T PLAN ON REVERSE SI <br />DEPARTMENT�ISE ONLY <br />DATE S�%L <br />GROUT INSPECTION PHASE III/FINAL INSPECTION <br />DATE INSPECTION BY DATE W - -2- <br />CALL <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 4/72 1M <br />