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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR OFFICE USE: 01'� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .72--66 <br /> 9 V6 ve <br /> THIS PERMIT EXPIRES 1 YEAR TROM 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 2542 S Wriest Lane CENSUS TRACT <br /> Owner's Name William Calif. Phone415 458 3577 <br /> Address 170 Garvin St. City San Francisco <br /> Contractor's Name J. A. Thalhamer Coo License # 272303 phone 477 1858 i <br /> TYPE OF WORK (Check) : NEW WELL /MM•/ DESPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / */ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 76 N. SEWER LINES 81ft-PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC TION <br /> Industrial Cable Tool Dia. of Well Excavation ( s <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing .109 N <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other * Rotary Type of Grout Cement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Moorman Water Systems <br /> Type of Pump Barnes submersible H.P. "ice <br /> PUMP REPLACEMENT: 1 / 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 <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 /> informatioon� is true to the best of my knowledge and belief. <br /> SIGNED q C i.C. i.....��1 TITLE <br /> V (DRAW PLOT LAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B [?fes DATE <br /> ADDITIONAL COMMENTS: ` 177 <br /> PHASE II GROUT INSPECTION PHASE I I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />