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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC Y' 0 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -, Telephone: (209) 466-6781 <br /> 1 PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> IF <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 /> JOB ADDRESS/LOCATION 3541 Stevenson CENSUS TRACT <br /> Andrew Card 465 9508 <br /> Owner's Name Phone - - - , <br /> Address .I, 3541 Stevenson City Stockton <br /> Contractor's Name I. J. A. Thalhamer Cow ' <br /> License #272.303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION f_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br />` DISTANCE TO NEAREST: SEPTIC TANK o_• SEWER L114ES _70rt-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> W . <br /> INTENDED USE: TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool Dia. of Well Excavation 10 inch <br /> Domestic/private $ Drilled Dia. of Well Casing 6 inc ' <br /> Domestic/public D7riven Gauge of Casing 09 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 f't• <br /> Other I * Rotary- Type of Grout Cement <br /> Other _ Other Information <br /> PUMP INSTALLATION,IIContractor . ' 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done = —. <br /> ESTRUCTION 0 ,T +Te Dia ter 0�*ners es on ibil' Approximate Dep h <br /> rube Material Fano„Proced re —1 <br /> ► 11 h I <br /> lI hb agree to ;comply with all/laws and regu tion of t e San oaqui Local HealthD' t <br /> andle/Ithe State of California pertaining to `or regulating well construction. Within FI EN <br /> after completion of my work on _a new well, I will furnish the San Joaquin Local Health Dis rict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> k information is true to the best, df my knowledge and belief. <br /> d <br /> SIGNED r I TITLE <br /> s <br /> I� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I 4 <br /> APPLICATION ACCEPTED BY DATF,,, <br /> ADDITIONAL COMMENTS`_ <br /> P CGROUT INSPECTION PHAS I PECTION <br /> INSPECTION BY // DATE INSPECTION BY E <br /> CALL FOR U NSPECTION PRIOR TO GROUTING AND FINAL IN <br /> 7/72 1M <br /> E H 1426 1 �I i <br />