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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,?.z eZp7E,J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y /7Jf <br /> . (Complete In Triplicate) ' <br /> Application is hereby made to 'the' Sin 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 `C`,smp WnOrl- nrrl Zed - � ,,,,_...__ CENSUS TRACT <br /> Owners Name Conrad Silva- '* Phone 4 8004 <br /> Address 1431 W. Walnut St. City Stockton <br /> Contractors Name J. A. 1halhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL A4/ DEEPEN /_/ RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / .PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK =. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INIENDED USE TYPE OF WELL ,t CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation winch <br /> - f P _ _ <br /> ' Domestic/ rivate Drilled Dia, of Well Casing , 2-�.,_inc_h <br /> Domestic/public Driven Gauge of. Casing Class 16O,: plastic <br /> Irrigation Gravel Pack Depth of Grout Seal 30 -.t.- <br /> Other Rotary Type of Grout 0earient, <br /> Labor camp "' Other Other Information <br /> PUMP INSTALLATION: Contractor . ^� <br /> �. Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> IL <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. .Withi'n_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 /> SIGNEDTITLE` <br /> - - - - --- - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l5' ) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION -- -- - -- PHASE. III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 7.M ' <br />