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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: !/ 1.601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7a <br /> E <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sara 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 4725 19. Eight Mile Rd. CENSUS TRACT <br /> Owner's Name Ed. M. Leon Phone 478 8666 <br /> Address 4725 W. Eight Mile Rd. City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License #272 303 Phone477 1858 <br /> _ <br /> TYPE-OF-WORK (Check): ANEW WELL *7 DEEPEN /_/ RECONDITION /77 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES 6U PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _( <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation lU inc <br /> Domestic/private Drilled' Dia. -of Well Casing 6 inch <br /> Domestic/public' ` Driven Gauge of Casing .109 (�`I <br /> Irrigation Gravel Pack Depth of Grout Seal 25 ft. <br /> Other Rotary Type of Grout Cement -- <br /> Other Other Information <br /> PUMP INSTALLATION: ContractorD. & V. .gip Co. <br /> Type of Pump. Shallow well. ,. tea... H.P. <br /> , ......,.,.1,.......,., <br />, PUMP REPLACEMENT: j_/ State Work Done <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diamete.r4 r- -,—�,--- -6 "- - - ----Approximate Depth 88 ft., <br /> Describe Material -and Procedure Cement grout <br /> I hereby agree to comply with all laws and regulations-of the San Joaquin-Local Health-Digtrict <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 /> 3 <br /> SIGNED,' dt-Gl 'v .: _ - ".. --'---- TITLELI'l ` <br /> 1 {DRAW. PLOT PLAN ON REVERSE.SIDE <br />} FOR DEPARTMENT USE ONLY <br />, PHASE I <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: = i <br /> - -PHASE II GROUT INSPECTION PHA I NAL""INSPECTION <br /> INSPECTION BY DATE n ..INSPECTION BY DATE <br /> r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426r� - �� 4 <br />