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SAN JOAQUIN ` &ELLOREALTH DISTRICT <br /> rFORg0FFjICEjUSff: <br /> ' 1601 E. tiazelton �ve. , Stockton, Calif. <br /> I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> it T <br /> THIS PERMIT -EXPIRES1 YEAR FROM DATE ISSUED Date Issued <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 20080 Ayers Ave. I � <br /> CENSUS TRACT —� <br />` Owner's Name Jack Satero I <br /> Phone 838 7783 <br /> Address � hoI - <br /> Satero' s 130 " p CityEscalon <br /> Contractor's Name J" k • Thalhamer Coo License #272 303 Phone x+77 1858' <br /> TYP;G OF WORK (Check): NEW WELL ,/,/���EEP,ENS/�►/+dRECONDITION�F/.g"' ,�-��DEST�iUCTION�'/�,�" � ��• �. ' <br />� 'PUMP INSTALLATION / / h:'UMP REPAIR' %.�'r/x�?�PUMP"'REPLACEMENT /� i I <br /> DISTANCE TO NEAREST: SEWAGE TANK >"I <br /> FIESEWERI! LINES PIT PRIVY- <br /> SEWAGE CESSPOOL/SEEPAGE PIT OTHER � ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � } <br /> Industrial _Ca 001 --Dia-.--of-Well--Excavation 0 inc <br /> G <br /> le yT <br /> Domestic/private. Drilled Dia. of Well Casing 6 inc <br /> Domestic/public Driven Gauge of Casing _ 0109 <br /> Irrigation Gravel ,Pack 1 Depth of-Grout Seal 50,_111t. _pl. s <br /> Other Rot ar �:. <br /> y p�`- Type of Grout Cement <br /> Other ✓ 'aj Other Information �. <br /> PUMP INSTALLATION.s ,r <br /> • Contractor 's <br /> T_ypejof Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:- — <br /> / / ,State Work,Done J- <br /> JDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> s Describe Material and Pocedure \ <br /> IIL <br /> g <br /> I hereby agree to comply with all laws, and re tilations 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 w111 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 /> SIGNEDLid ji - (DRAW PLOT TITLE�V <br /> PLAN ON REVERSE SIDET <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY \„ <br /> DATE -7, ° <br /> ADDITIONAL COMMENT ! <br /> P I ROUT INSPECTION P I INAL INSPECTION <br /> INSPECTION BYDATE = 27-- INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M r <br />