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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO <br /> R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z �✓ <br /> THIS PERMIT EXPIRES l 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 /> r aT`f4'w <br /> JOB ADDRESS/LOCATION On N. side of tPeltier-Rd., 1060 ft. E- of Blossom Rct}ENSUS TRACT 9l(-d <br /> Bob Ceechin <br /> Owners Name i Phone 478 1881_ <br /> Address <br /> 7518 Camellia Lane City Stockton <br /> Contractor's Name <br /> S. A. Thalhemer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /? RECONDITION /_� DESTRUCTION -_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP,REPLACEMENT /-7 <br /> Other . — ` <br /> DISTANCE TO NEAREST: SEPTIC TANK 17 Tt. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tbol Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well, Casing.. <br /> Domestic/public Driven Gauge ofCasing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> _ Other Rotary Type of Grout <br /> Test well Other Other Information, <br /> PUMP INSTALLATION: Contractor 11. G. Noack Inc. <br /> Type of Pump Centrifigul H.P. - 5 <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:- _ State Work Done <br /> i ,pESTRUCTION 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 Californiaipertaining 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 TITLE` 1)_,.0 _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED,BY DATE . <br /> AD6ITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE j '� <br /> 1 ^� --- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, 7/72 1M - <br /> E H 1426 <br />