Laserfiche WebLink
SAN JOAQUII LOCAL HEALTH DISTRICT 4 3 53 <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 /> ""� `C THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (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 2733 S. Airport Way CENSUS TRACT <br /> Owner's Name Helen Cerri Phone 982 4865 <br /> Address 2733 S. Airport Way City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License #272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_J RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR —/—/ PUMP REPLACEMENT /7 <br /> Other /-7 <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 16)�ft• OTHER �tt <br /> V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation nc <br /> * Domestic/private Drilled Dia. of Well Casing 6 inc <br /> Domestic/public Driven Gauge of Casing -0109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other ** Rotary Type of Grout Cement '1 <br /> Other Other Information own <br /> PUMP INSTALLATION: Contractor Moorman Water Systems "r <br /> Type of Pump Barnes submersmble H.P. <br /> PUMP REPLACEMENT: / / 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 topp the best of my knowledge and belief. <br /> SIGNED y///t <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -° j� 7 , DATE l —7 -1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT <br /> INSPECTION BY DATE l�7 7J? INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C <br />