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�.�._ SAN JOAQUIN 19CAL-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./ .,3_le <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , -�3 <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 /> S'1 <br /> JOB ADDRESS/LOCATION 4800 E. Hildreth Lane CENSUS TRACT <br /> Owner's Name. Dennis Green Phone ' 478 0544 <br /> Address 345 Yorkshire ` s City Stockionr, <br /> J. Ae Thalhamer Co. 72 303 477 1858 <br /> Contractor's Name - License Phone one <br /> TYPE OF WORK (Check) : NEW WELL fi*/ DEEPEN / / "RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP- REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7O t. SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> x INTENDED USE TYPE•OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dla._of Well Excavation 10 Inckir <br /> Domestic/private .Drilled Dia. of We11­Cas"3ng� inch. __ V� <br /> E Domestic/public f Driven Gauge of Casing - .109 P <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other - Rotary Type of Grout Cement <br /> Other Other Information <br /> k PUMP INSTALLATION: Contractor 4Jniv-- s -+u=Pr1G'm Moorman 'dater Systems <br /> Type of Pump Submersibles H.P. <br /> F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done _ w <br /> '.RESTRUCTION OF, WELL:­a: 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 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 /> ��,, 1l. <br /> SIGNED i TITLE!( eek <br /> CY (DRAW PLOT FLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,`: . <br /> APPLICATION ACCEPTED BY DATE I. �2.� <br /> ADDITIONAL COMMENTS: <br /> - 'PHASE II GROUT INSPECTIO PHASE- IIi F NAL INSPECTION- <br /> ,C <br /> INSPECTION BY DATE /�, ' �� INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 7/72 "i1__ <br />