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L � SAN�'JOAQUIN LOCAL HEALTH DISTRICT �z 5 <br /> FOR OFFICE USE: 16I�1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> • _ v APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 7 Z_S-`� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /D-/a• 7y <br /> - ° (Complete In Triplicate) <br /> Application ismhereby 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 Joaquit <br /> County Ordinance-No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4725 W. Eight M&le Rd* CENSUS TRACT <br /> Owner's Name = -,Ed: M: Leon Phone 7$ 866$ <br /> Address _4725 W. . Eight Mile Rd. City Stockton <br /> Contractor's Name <br /> J. Ao Thalhamer Co. License 41X72 503 Phone x+77 1853 <br /> t TYPE OF WORK (Check) : NEW WELL /*;/' DEEPEN / / RECONDITION /_7 DESTRUCTION' /-7 <br /> PUMP INSTALLAATION / { PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC Tlh�N SEWER LINES80 f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ <br /> Industrial Cable Tool Dia. of Well Excavation— inch � <br /> E s Domestic/private Drilled Dia., of Well Casing_ ` inch <br /> Domestic/public Driven 1 �\ Gauge of Casing .-109 1 <br /> Irrigation Gravel Pack Depth of Grout Seal Q_ <br /> Other Rotary Type of Grout _ Cement. <br /> Other �� Other Information <br /> f PUNK' INSTALLATION: Contractdr Owner E <br /> Type, of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate'De-p-th <br /> None Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> lafter 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 _ F G TITLE Gev✓+-�^r. T <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �..�IFIO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED S DATE Y <br /> ( ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECT N PRIG T© GROUTING INAL INSPECTION. <br /> E H 1426 jX 7%72 1M <br />