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T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFO !OFFEICE* USE: 1601 E. Hazelton'Ave.#,S"tockton, Calif. 19 <br /> Telephone.: (200),,.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION' OR PIMP PERMIT Permit No.7 <br /> THIS PERMIT -EXPIRES,l�.YAR4FROM DATE ISSUED Date Issued <br /> I ,i <br /> (Complete `In'�Triplicate) <br /> Application',is .hereby-imade:Y,to :thexSanyJbaquin: 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 a No:r1862 and:the. Rules,and .-Regul. iions .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1168 Cochran Rd. f CENSUS TRACT <br /> } (T an', <br /> Owner's Name _ Mrs 1da-Behlenkern . l r r. 6 4011 F <br /> Phone <br /> Address._ 812 S. Orange City Lodi <br /> Contractor's Name J. A. Thalhamer Coo M ' <br /> License #272 303 Phone 477 1858 � <br /> . . .,. 11 .. . . . <br /> RK . . <br /> d _ <br /> TYPE OF WO (Check) : NEW W$LL /*:/ DEEPEN '%/ R.�iCONDITION / /_DESTRUCTION <br /> PUMP��INSTALLA`'ION '/+�7J - PUMP iREPAIR ./ PUMP REPLACEMENT /7 <br /> Other <br /> � I r <br /> DISTANCE TO NEAREST: SEPTIC TANK 59 fte SEWER LINES PIT PRIVY ! <br /> SEWAGE .DISPOSAL FIELD CE$SPOOL/SEEPAGE._PIT., OTHER .--� <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool �Fbia, of Weil Excavation 10 inch <br /> Domestic/private ;.`Drilled Dia, of Well Casing _. inch <br /> '�. Domestic/public Driven <br /> -- �4Gauge.of Casing .109 (� <br /> Irrigation Gravel i Pack bepth__of,Grout..Sea'1_. y� <br /> Other +� <br /> Rotary Type of Grout Cement <br /> 'Other Othdi,;Jnformation <br /> PUMP INSTALLATION; Contractor A. Thalhlamer Coo <br /> Type of Pump Barnes subm6rsible <br /> - _ -H.P_. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Worm Done. <br />,DESTRUCTION OF WELL: Well Diameter Owners res onsibili t _j <br /> P y Approximate Depth 1Fl ft. <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 to the best of my knowledge and belief. <br /> SIGNED, <br /> TITLE <br /> PLOT PLAN IKON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE 8 j <br /> ADDITIONAL COMMENTS: I <br /> PHA E II GROUT INSPECTION FHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE -- fes= INSPECTION BY DATE <br /> S 4 <br /> CALL.FOR. A ,GROUT.I,NSPECTION_PRIOR TO GROUTING AND' FINAL INSPECTION. <br /> E H 1426 � .. <br /> 4/72 1M <br />