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SAN JOAQLffN* L6tAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d -L60 <br /> -Iiv JA .,-q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereb de 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 8755 Alhambra St. CENSUS TRACT <br /> Owner's Name Richard Rasmuss@n Phone 466 2652 <br /> Address 825 Rio Pico City Stockton <br /> Contractor's Name J. A. lhalhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL /* / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK •SEWER LINES 114 M-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER op <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation M inch <br /> * Domestic/private _ Drilled Dia. of Well Casing 6 inch D <br /> Domestic/public Driven Gauge of Casing .109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other * Rotary Type of Grout Cement �a.- <br /> Other Other Information <br /> W� <br /> PUMP INSTALLATION: Contractor J. A. halhamer Cor <br /> Type of Pump Barnes suomersible H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> 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,,.4,', <br /> t (DRAW PLOT PLAN ON REVERSE SIDE)� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �\�` DATE <br /> ADDITIONAL COMMENTS: <br /> PHA E II GROUT INSPECTI N PHASEIII FINAL INSPECTION <br /> INSPECTION BY DATE 3 INSPECTION B E' of,,zo!� ;3;7 <br /> CALL FOR A G T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ! 4" <br /> E H 1426 7/72 1M <br />