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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USI;: . 1601 E. Hazelton: Ave., Stockton, Calif <br /> jl Telephone: ° (209) 466-6781 �, . N <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPgE-R-M Pe!rinxt No. Z- �{� <br /> I <br /> THIS PERMIT EXP'IRES.,l-YEAR'`FIO�f DATE ISSUED Date Issued 771- <br /> - (Complete <br /> 7- (Complete In Triplicate) <br /> Application ,is !hereby'.,madeito the San7Joaquin�Local- Health'District fora permit to construct <br /> and/or install the workl[herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance .No. ")1862 and�!the.,RulesfrandkRegulatioils' of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION JJ Dos Reis Rd, W. of Hiway 50 CENSUS TRACT ' <br /> -, 462 8209 <br /> Owner!s Name= :.: : ,Charles ,Coleman <br /> Address ; :� r ,- .._. Phone <br /> '. <br /> 801 S. Lincoln St. /�, City Stockton <br /> �. 272 ; 477 1858 <br /> Contractor's Name d• A. Thalhamer Co. License # Phone <br /> I� <br /> TYPE OF WORK (Check) : -NEW WELL""/ DEEPEN"`/ /'`RECONDITION /�{'DESTRiICTION /rT <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> ` <br /> Other ! / <br /> I � <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k a� <br /> - INTENDED USE ' ' TYPE OF WELL-- -� CONSTRUCTION SPECIFICATIONS IFR) <br /> In0 ft <br /> dustrial Cable Tool Dia. of Well Excavation App.Domestic/private Drilled Dia. of Well Casing inch <br /> 4 Domestic/public f Driven Gauge of Casing •109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50ft. <br /> Other Rotary Type of Grout Cla <br /> n�. Other Other Information <br /> I <br /> .- <br /> PUMP INSTALLATION: : Contractor J•"A Thalhamer Co. <br /> ,Type of Pump Barnes submersilil`e H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r, <br /> PUMP REPAIR: / / State Work Done _ <br /> .DESTRUCTION OF WELL: Well Diameter '� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to .compa'y with all laws and regulation's of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well constructi�an. Within FIFTEEN DAYS <br /> after completion of myl'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 /> TITLE <br /> i SIGNED r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE J� <br /> APPLICATION ACCEPTED BY _ i — <br /> . ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE 11�!GROUT INSPECTION <br /> INSPECTION BY DATE pj �--- INSPECTION BY .. DATE Z <br /> E: <br /> CALL FOR A GROUT INSPECTION PRIOR..TO.,GROUTING 'ANA FINAL INSPECTION. 4172 <br /> E H 1426 <br />