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w <br /> rim SAN JOAQUIPL LOCAL HEALTH DISTRICT 11 <br /> FOR OFFICE USE- 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone (209) 466-6781 f' <br /> ICATIOA FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. si W �N <br /> [ 73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - Y� <br /> (Complete In Triplicate) <br /> Application in 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 Joetdn <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distr)ct. <br /> JOB ADDRESS/LOCATION 2733 S. Airport Way CENSUS TRACT <br /> Helen Cerri 982 4865 J <br /> Owner s Name Phone <br /> Address 2733 S. Airport Way City Stockton <br /> J. . Thalhamer Co. 272 303 477 1858 <br /> Contractor•s Name ALicense B Phone i <br /> TYPE OF WORK (Check): NEW WELL o—T DEEPEN /7 RECONDITION /� DESTRUCTION /7 <br /> PIiMP INSTALLATION /�] PUMP REPAIR / / PUMP REPLACEMENT T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANWj SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT 187 ft- OTHER <br /> • INTENDED USE TYPE OF WELL CONSYRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a +, <br /> 4 Domestic/private Drilled Dia. of Well Casing 6nc •� F° <br /> Dowstie/public Driven Gauge of Casing 0109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. �,• <br /> Other " Rotary Type of Grout Gement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ?Moorman '.inter Systems - <br /> Type of Pump Barnes submersAble H.P. i r <br /> PUMP REPLACEMENT; / / State Work Done <br /> ! YA <br /> PUMP REPAIR: / / tate Work Done r„ <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 Californi.+ 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 Dietriem a <br /> WELL GRILLERS REPORT of tree well and notify them before putting the well in use. The above . <br /> information is true to the best of my knowledge and belief. t <br /> . , TI1LE 4 <br /> SIGNED [ <br /> DRAW PLOT PLAN ON REVERSE SIDF is <br /> FOR DEPARTMENT USE ONLY - tt <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY d 11 <br /> ADDITIONAL COMMENTS: r� <br /> PHASE LII FINAL INSPECT <br /> PHASE II GROUT INSPECTION r, 3 <br /> IbiSPECTION BY DATE lyl S 73 INSPECTION BY DATE <br /> CALL FOR ACROVX IIiSPECTION PRIOR TO GROUTING AND FINAL INSP=ION. - <br /> E R 1626 <br /> - 7/72 11M 11c; <br /> -rS <br /> 4-7 <br /> w <br />