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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USEe 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI�r.'�'� ; � fPermit <br /> . THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ti Date is- ed 111117-3'� -ow�SL'' ••J� ,2D; (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 Camp 1, Woodward Island CENSUS TRACT <br /> Owner's Name Conrad Silva Phone 463 8Q04 <br /> Address 1431 W. Walnut St. City Stockton <br /> Contractor's Name Jo A. Thalhazn,er Co. License # 272 303 Phone477 1853 <br /> TYPE OF WORK (Check) : NEW WELL /*/ DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ •S-EWER LINES - 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 7 inc <br /> * Domestic/private Drilled Dia. of Well Casing 5 inc <br /> Domestic/public Driven Gauge of Casing Class 2001 <br /> Irrigation Gravel Pack Depth of Grout Seal 25 ft. <br /> Other * Rotary Type of Grout Cement <br /> Other Other Information <br /> Q <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> t . C/ <br /> SIGNED 'lf TITLEG�), �~ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> 2 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY BATE 111122 <br /> .727 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />