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r. FOR SFFIC 1 L '�'LAQUIN LOCAL IU;ALTH DI.STRIC7 <br /> / 1601 E. Ilazeitcn Ave., Stockton, Calrf. <br /> ( Tc1- hone: <br /> P (209) 466-6781 q <br /> APPLICATION FOR WELL CONSTF!ICT1GN Olt pvU-u PEGMIT Permit No. 72 <br /> r V <br /> THIS_ PE_RMI1: EXPIRES 1 YEAR FROM DATE _ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t0 the Sall Joaquin Local Jealth District for a permit to cons*ruct <br /> w and/or install the work herein described. This application is made in compliance with San ?oaquir. <br /> County Ordinance No. 1862 and the Rules and Regul.atioas of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3541 Stevenson CENSUS TRACT <br /> r <br /> Owner's Name Andrew Card Phone 465 9508 <br /> . s <br /> Address _ - 3541 Stevenson - City Stockton <br /> Contractor's Name _ J. A. Thelhamer Co. License !1272 303 Phone 477 1959 <br /> TYPE OF WORK (Check): NEW WFLL j DEEPEN / / RECONDITION %% DE•STRUCTION /_7 <br /> PUMP INS:'A�.LATION PUNQ REeAIR / J PUMP REPLACEMENT /7 <br /> Other / ,- _ <br /> DISTANCE TO NEAREST: SEPTIC ":'ANK�`r``�' SEWER LINES .PIT PRIVY <br /> SEWAf,E DISPOSAL FIELD _ _ CESSPOOL/SEEPAC,E PIT OTHER W <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tao!. Dia. of Well Excavation_ 10 Ines <br /> + Domestic/private Drilled Dia, of Well Casing cncr. <br /> Domestic/public J,ive_n Gauge of Casing <br /> r _ Irrigation Gravel Pack Depth of Grout Seal 50 Ft. y <br /> Other _ ++' Rotary Type of Grout Ceaent t� <br /> - Other _ Other Information 3 <br /> PUMP INSTALLATION_: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% state Work Done <br /> PUMP REPAIR: / / State Work <br /> Done ..� ,y! <br /> ESTRUCTION Ol� .�3Le ri,.S ter Ow�era {esoon ibil' !/ ApproximatOt e Dep h 4 <br /> ' / k�ipe Material andd.Proced re _ <br /> ` I h b agree t0 comply with ail awr: and t0gu tion of the San Joaquin'Local Healt D' t <br /> and /the State of California pertaining to or regulating well construction. Within Fi EN <br /> after completion of my work or- a new well, I will furnish the San Joaquin Local Health Pis rict c. <br /> WELL DRILLERS REPORT of the well and nocif, thew before putting the well in use. The above <br /> information is true to the best. of my knowledge and belief. <br /> ` SIONED! - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r FOR DEPT*_:NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYt '�y�.�' i __-__ DAT- JD- <br /> ADDITIONAL COMMENTS.- _ <br /> P L/'BROUT INSPECTION PHASE I/ PECTION <br /> INSPECTION BY,/-.-/ / DATE INSPEGTIOD: BY E <br /> CALL IDR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 _ j 7/72 1M <br /> r <br /> r <br />