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l SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E, 3�17-3 <br /> (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 10000 Calpack Rd. Union Island ENSUS TRACT <br /> Owner's Name Rodolfo Mussi phone 465 8663 <br /> Address 10000 Calpack Rd. City Stockton t <br /> Contractor's'Name J. A. Thalhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL /*7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTZLATION / / PUMP`REPAIR / / PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 8 1"t. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial . Cable Tool Dia. of Well Excavation 7 inc <br /> ►�* Domeestic/private 6k illed Dia. of Well Casing 3 inc <br /> Domes 1 <br /> is/puryblic "-'�` Driven Gauge of Casing Class 200, plastic <br /> Irrigation Gravel:­Pack Depth of Grout Seal 25 ft. <br /> Other Rotary Type of Grout Dement <br /> Other Other Information 1 <br /> PUMP INSTALLATION: Contractor { <br /> Type of =Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP REPAIR: / / State Work Done " <br /> ,DESTRUCTION OF WELL: Well DiameterApproximate'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 ,furhish 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 s <br /> information is true to the best of my knowled•ge .•and belief, <br /> SIGNED <br /> (DRAW PLOT_ PLAN_ON_.REV_ERSE SIDL <br /> FOR DEPARTMENT USE ONLY -- - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION " ' """ "-' PRASE I FINAL INSPECTION � f <br /> INSPECTION BY DATE INSPECTION B� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. —W <br /> E H 1426 7172 1M f <br />