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`io � N JOAQUIN LOCAL HEALTH DISTRIC^ 'I <br /> CM N <br /> FOR OFFICE USE: 16:,._ E. Hazelton Ave. , Stockton, Cali. o_ <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 -3,1- <br /> (Complete <br /> ,/- <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -nd/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 /> lol`M W <br /> OB ADDRESS/LOCATION On N. side of Peltier Rd. 1060 ?t. L. Of BlOssOm RtENSUS TRACT D!(--oLW -o Z <br /> fkoner's Name Bob Jecchini Phone 478 1881 <br /> Address 7518 Camellia Sane City Stockton <br /> ontractor's Name J. A, Thalhamer Co. License 11 272 z0% Phone 477 185' <br /> YPE OF WORK (Check) : NEW WELL )�W DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> O <br /> ISTANCE TO NEAREST: SEPTIC TANK 15 "x SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Test we11 Other Other Information <br /> -RUMP INSTALLATION, Contractor i'r. 3. Noack Inc. <br /> Type of Pump Jentrizig•ul H.P. 5 <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP REPAIR. / / State Work Done <br /> aESTRUCTION 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 /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .fter 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 /> nformation is true to the best of my knowledge and belief. <br /> SIGNED ��, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDESE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I % <br /> -RPPLICATION ACCEPTED BY ,P. DATE `�/ I /7o_ <br /> DDITIONAL COMMENTS: �` ']`"` <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY <,'. DATE , INSPECTION BY lr� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />