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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USS: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.l__- y&, <br /> t THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,._13 73 <br /> I��Ctr.,T,q ;V (Complete In Triplicate) t <br /> Application is` hereby ma& . tie San Joaquin Local Health District for a permit construct <br /> and/or install the work herein described. This application is made in compliance with San J'oaquii <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Westside Tracy .island R d. 1 mile S. of Hivay 4 CENSUS TRACT <br /> Owner's Name A. Volpi,, ' '46 8745 <br /> • t . <br /> Phone 3 <br /> Address 1245 w. Walnut St. Stockton <br /> City,_. <br /> Contractor's Name , J. A. Thalhamer Coo r License #272 303 Phone 477 18-98 <br /> TYPE OF WORK (Check): NEW WELL t,/ DEEPEN /'7; RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> + Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 161 i't•PTT 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 6 inc <br /> Domestic/private Drilled Dia-. 'ofgWell Casing 8 in ch <br /> Domestic/public; Driven Gauge of Casing .109 <br /> Irrigation Gravel Pack Depth of .Grout Seal None -Ewa <br /> Other I Rotary Type of Grout None <br /> Asparagras washer F Other Other Information <br /> PUMP INSTALLATION: Contractor s r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter t t <br /> - - _ Approximate Depth <br /> { Describe Material and Procedure <br /> s <br /> I hereby agree to comply with all laws.-and-regula-t-fons 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 i tV6'IfCCCuC TITLE, <br /> a <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY0, DATErf <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION PHAS T FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROUT INSPECTION_PRIOR TO GROUTING. AND FINAL INSP CTION <br /> E H 1426 " ` <br /> t . . 7/72 1M <br />