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zellz /2. ��^ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(Complete In 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 2044 S. Airport Way CENSUS TRACT <br /> Owner's Name Martin Cerra /t/bCC 6cvNC�� C i Phone 462 0472 <br /> Address 2044 S. Airport, Way City Stockton <br /> Contractor's Nam J. A. -Lhalhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL /T DEEPEN /7 RECONDITION /-[ DESTRUCTION <br /> P ' TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> 0 emove pump from we <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable .Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> All structures removed from the property , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 "r <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. �s <br /> SIGNED r ti,� (^�.,�...t� TITLE�2A, Crime...- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �'- �' Z.. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D TE <br /> CALL FOR A GR UT INSPECTION RIO I� 0 GRO TI G AND FINAL INSPECTION. 71/z17zcH �, � <br /> E H 1426 /Z���/72; l.�eQ� .�2� — �- Ch l2//2/)t2� it���73- '% 7/72 1M "� . <br />