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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />' Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �o7_/yc/ GJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J- <br /> (Complet'e 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 3444 Section Ave. V.of 99 Hiway CENSUS TRACT <br /> Owner's Name L. S. Me Pherson Phone 465 4637 <br /> Address 3444 Sectio n. Aveo W. of 99 Hiway City Stockton <br /> Contractor's Name J. A. Thalhamer Coo License #272 303 Phone477 1858 <br /> TYPE OF WORK (Check) : NEW WELL / /^ DEEPEN /*-7 _REGONDITION F7 DESTRUCTION- /-7 <br /> PUMP INSTA LATIONJ/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 T <br /> DISTANCE TO NEAREST: SEPTIC TANK _5.2�ft. SEWER LINES 62 ft. PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD �T CESSPOOL/SEEPAGE PIT OTHER <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial Cable Tool - Dia. of Well Excavation Inc - .� <br /> ' Domestic/private Drilled Dia. of Well Casing 6 inc <br /> Domestic/public Driven Gauge of Casing 12 guage <br /> ' Irrigation Gravel Pack Depth of Grout Seal one <br /> Other * Rotary Type of Grout <br /> Other Other Information Deepen and install 50 ft. <br /> 5-inch casing as a liner. <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF.WELL: Well Diameter Approximate Depth <br /> None Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> Viand the State -o€ 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. �j�ke_ ,D <br /> SIGNED9TITLE of <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ , y, DATE L <br /> ADDITIONAL COMMENTS: 42 01 <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 INSPECTIO . <br /> E H 1426 '_ 7/72 1M <br />