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SAN JOAQUIN LOCAL 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. <br /> s <br /> WFC- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �tf <br /> CA-To _�f b_"• (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 Camp 6, Woodward Island, South side <br /> CENSUS TRACT <br /> Owner's Name Eddie Lucchesi Phone 478 5473 <br /> Address 3+23 Millspring Drive City Stockton <br /> Contractor's Name J• A. Thalhamer Go* License # 272303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL fWl- DEEPEN /_/ RECONDITION 17 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIIfs AJ ONS # <br /> Industrial Cable Tool Dia, of Well Excavation a } <br /> Domestic/private Drilled Dia, of Well Casing 3 inch <br /> Domestic/public Driven Gauge of Casing Claes 200 plastic ! F <br /> Irrigation Gravel Pack Depth of Grout Seal Min. 25 f't. -,k <br /> Other Rotary Type of Grout Cement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />.PUMP REPAIR: / / State Work.-Done <br /> ESTRUCTION 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 -wont on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and .notify them before `putt-ing-the-well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,1 <br />' APPLICATION ACCEPTED BY DATE / a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIJIFINAL INSPECTION <br /> INSPECTION BY- DATE INSPECTION -BY _j&d14 DATE � 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />