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y � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Gd�k a Z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 2796 631. Undine Ind. CENSUS TRACT <br /> Owner's Name Ivan Cerri Phone .465 86 +1 <br /> Address 2796 N. Undine Rd. City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License # 272 303 Phone 477 185B <br /> TYPE OF WORK (Check) : NEW WELL /+M / DEEPEN /_7 RECONDITION /� DESTRUCTION /,-7PUMP INSTALLATION / / PUMP REPAIR /—/ —PUMP REPLACEMENT, /-T <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER: LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIfACQTIQNS <br /> Industrial__ -_,,. ---Gable-Tool - Dia. of. Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 6 inch plastic POW <br /> Domestic/public Driven Gauge of Casing Finch wall <br /> Irrigation Gravel Pack Depth of Grout Seal - 20 ft. <br /> Other - Rotary Type of Grout Cement <br /> Other Other. Information irk <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / : % State Work Done--- - <br /> PUMP <br /> one -PUMP REPAIR: /< / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> 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 California 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 /> %.-ASIGNED - w TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE-I-I-GROUT._INSPECTION,­_._____._,.__-.... __. ..-- - ---.- .. -•PHASE' _ NAS.'I PECTION <br /> INSPECTION BY DATE INSPECTION,: BY E - - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . E H 1426 7/72 1M <br />