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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1/1601 E. Hazelton Ave. - Stockton, Calif. <br /> �_ . - Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZI <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. j_�,470 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION P'ernwood CENSUS TRACT <br /> Owners Name 111n.-ohell Sons Phone 462 <br /> Address ._ _ _ 3835 E. Main.St. City Stockton <br /> Contractor's Name J. A. Thal}7f3Tb�T' Co. _ _ � i 1E, License # 2.72 Nfl Phone477 1858 <br /> . <br /> t <br /> TYPE-OF-WORK .(Check) NEW WELLrA.-*7 DEEPEN;-/--7-=RECONDITION. /?�DESTRUCT30N/�� <br /> PUMP INSTALLATION /,/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO-NEAREST:—SEPTIC TANK `8 SEWER LINES 9 ft. IT PRIVY <br /> c SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I INTENDED USE TYPE OF WELL . iCONSTRUCTION SPECIFICATIONS <br /> Industrial K T Cable -Tool- --- -==-Dia-.-of'Well Excavation 10 inch <br /> k Domestic/private Drilled Dia. of; Well Casing 6 inch v <br /> I .- Domestic/public Driven Gauge of Casing .ZO <br /> ` t *" Irrigation Gravel Pack Depthof Grout Seal 50 ft. plus <br /> E :~f Other Rotary Type of Grout <br /> Other ; Other .Information <br /> c <br /> r PUMP INSTALLATION: Contractor ; <br /> ¢ Type of Pump <br /> yl <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> iF <br /> PUMP REPAIR: / / State Work Done <br /> ' EST-RUCTION OF WELL:- -WeZ1=Diameter Appr`oxtm'ate-Depth <br /> Describe Material and Procedure <br /> I hereby agxee to comply with all laws and regulations of-the San JoaquinLocalHealth District <br /> and the State of,California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of nmy 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 tlee-best of my knowledge and belief. <br /> A <br /> kSIGNED . , .�... TITLE � � <br /> 42 '(DRAW PLOT PLAN ON REVERSE SIDE <br /> -FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY AV .� t DATE F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION^ � '� PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE rD INSPECTION BY DATE ' <br /> CALL FOR A GROUTINSPECTION PRIOR TO GROUTING AND FINAL INSPECTION..-. . ,, <br /> E H 1426 7/72 1M <br />