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f - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 46LLe_V4_11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued S-1- <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 /> Pi`o T.Tf'q�w <br /> JOB ADDRESS/LOCATION - On N. side offpertier-"Erle= 1060 ft. E. of Blossom. R(}ENSUS TRACT 0l{.-04V',02; <br /> Owner Ia Name Bob Ceedhini Phone 478 1881 <br /> Address 7518 Camellia Lane ` City Stockton <br /> Contractor's Name J. A. 'Thalhamer Cos License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL _47 DEEPEN 17 RECONDITION I—T DESTRUCTION I-T <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PumpIREPLACEMENT /? <br /> Other ./ -/ - O <br /> DISTANCE TO- NEAREST: SEPTIC TANKJ�f4 . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 'OF WELL ' CONSTRUCTION SPECIFICATIONS , <br /> f 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 voll Other Other Information, <br /> 4 <br /> PUMP INSTALLATION: Contractor tri. G. Noack Inc. <br /> Type of Pump Centrifigul H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:- / / State Work Done <br /> i ,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 Calif orniaf/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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE�1�1 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY _ DATE - <br /> ADDITIONAL COMMENTS: ` <br /> 1PHASE II GROUT INSPECTION PHASE IIIc FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY1p DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 2 R 1426 7172 1M <br />