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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktnxl,, Calif. <br /> Telephone: (209) 46;6-6781 w� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 3 I58 <br /> -73- 1(- -:1P <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued�-73 <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' he Rules and Regulations of the San Joaquin Local Health District. <br /> s <br /> JOB ADDRESS/LOCATION 71211. Main St. CENSUS TRACT <br /> 462 8273 <br /> Owner's Name R: D:��..,Rorrow Phone r <br /> Address 7121 E. Main. St. City Stockton <br /> f <br /> Contractor's Name J. A. Thalhamer Co. License #272 503 Phone 477 1858 { <br /> f f <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP'REPLACEMENT /� <br /> Other <br /> t � <br /> DISTANCE TO NEAREST: SEPTIC TANK • SEWER DINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE--P-IT OTHER <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable ,Tool. -- -Dia,of=Well-Excavation Inc rn f <br /> Domestic/private 1 Drilled Dia, of Well Casing 6 inc <br /> Domestic/public t Driven Gauge of Casing •109 <br /> Irrigation i Gravel Pack Depth of Grout Seal 50 f't. <br /> Other — Rotary Type of Grout Cement <br /> I Other Other Information 'iJ <br /> 44— <br /> PUMP INSTALLATION: Contra,tnr Owner <br /> Type of Pump Submersible H;P. -- <br /> - <br /> PUMP REPLACEMENT: / / State Work Done.' ' <br /> PUMP REPAIR: / j State Work Done I <br />' .PESTRUCTION OF WELL: Well Diameter Approximate Depth +! <br /> l Describe Material and Procedure <br /> t. <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. ;I <br /> SIGNE , ' TITLE Zl <br /> R (DRAW PLOT PLAN ON REVERSE SIDE <br /> t <br /> FOR-DEPARTMENT USE ONLY <br /> 1 PHASE I t -- <br /> APPLICATION ACCEPTED BY ��, 0 ,; _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE. II:.GROUT:-INSPECTI N-•- PHASE III FINAL INSPECTION ..- <br /> INSPECTION BY DATE S INSPECTION BY DATE 6 <br /> CALL FOR A GROUT INSPECTION_PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 7/72 1M �� <br />