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�SAN JOAQU N LOCAL HEALTH DISTRICT 11 <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. I3-(S <br /> ' 73-IbZP <br /> THIS PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 'Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 /> e JOB ADDRESS/LOCATION 9303 Hildreth Lane CENSUS TRACT <br /> Owner's Name E. 'C. Loche Phone <br /> * 3196 <br /> Address 7620. 11. El Dordo St. Apt. 21 Stockton <br /> s. <br /> City <br /> ` 272 3O3 477 1858 <br /> Contractor 's Name J. A. 'Phalhamer Co. License _.Ph <br /> one <br /> Old <br /> TYPE OF WORK (Check) : NEW WELL/*7 DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /7 <br /> AL _ <br /> PUMP INSTALLATION /✓/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 74 Tt"@ SEWER LINES PIT PRIVY <br /> r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` INT_ENDED_USETYPE OF WELT. CONSTRUCTION SPECIFICATIONS <br /> k <br /> Industrial Cable <br /> Cable_Tool', Dia. of Well Excavation 1 inc <br /> * Domestic/private" '�T J .-Drilled Dia. of Well Casing i6 -inc <br /> ' Domestic/public Driven Gauge of Casing .109 <br /> Irrigation `Kx Gravel Pack, ^ ; Depth of Grout Seal. 50 ft. <br /> Other Rotary Type of Grout Cement <br /> N Other t Other Information � « <br /> PUMP INSTALLATION: 'Contractor Owner, <br /> ;Type of Pump Sears 5ubmersible ;' f H.P. 12 <br /> h �J <br /> PUMP REPLACEMENT: ` / / State Work Done <br /> 1 <br /> [-PUMP-REPAIR: - Vii/ / State-Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter.. . ; �, Approxi4ate 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 t& ,or regulating.-well-constru-cti-on:'-"Within FIFTEEN DAYS. <br /> after completion of my;.work on a new well, L will furnish the San Joaquin Local .Health. Distriet a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. TFi above <br /> information is true to.the best of my knowledg6 and belief,. , <br /> SIGNED . . I�t� �` TITLE7,W > <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> J PHASE I ' <br /> s APPLICATION ACCEPTED- BY.r f DATE <br /> YDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL'INSPECTION <br /> [ INSPECTION BY DATE `` <br /> r� INSPECTION BYDATE <br /> r 4 <br /> CALLIFOR A GROUT INSPECTION PRIOR' TO GROUTING AND FINAL INSPECTION. ` <br /> E H1426 7/72 1M <br /> 17 1 <br /> - - <br />