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J/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: GGG��� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-x- 4 <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued /a. -/0-73 <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 4973 4- CENSUS TRACT <br /> Owner's Name Floyd M. Hanson Phone None <br /> Address 216 E. 20th Street City Tracy <br /> Contractor's Name. J. A. Thalhamer Co. License # 272 343 Phone 77 1858 <br /> TYPE OF WORK (Check) : NEW WELL /*Y DEEPEN /_/ RECONDITION 1-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK8()ft7 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation nc V <br /> ��- Domestic/private Drilled Dia. of Well Casing 6 inch <br /> Domestic/public Driven Gauge of Casing -- <br /> x_ _Irrigation....,...— . Gravel-,Pack Depth -of Grout Seal 50 ft. <br /> Other Rotary Type of Grout Cement <br /> { Other Other Information <br /> PUMP INSTALLATION: Contractor 111. G. Noack Inc. <br /> Type of Pump Fairbanks Morse submersible H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate 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 furnish the San Joaquin Local Health Distrie 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 TITLE 1t/,,� _ <br /> W(BRAW PLOT PLAN ON REVERSE SIDE, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYe:;�, 242EZeflelcDATE Z2 <br /> ADDITIONAL COMMENTS: <br /> _PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSr TION. <br /> E H 1426 7/72 1M <br />