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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,. . <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. T 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �--t <br /> (Complete In Triplicate) <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a permit t+ 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 100 E. Holt Rd, CENSUS TRACT { <br /> Owner's Name Clem Christobal Phone 282 2651 <br /> Address 7 TOPa:t Way Cit ySan Francisco <br /> Contractor's Name J• A* Thalhamer Co. License �� 272 AD- Phone 477 1858 F <br /> TYPE OF WORK (Check): NEW WELL /*_/ DEEPEN / / RECONDITION /_7 DESTRUCTION-/-7___ <br /> N-9 <br /> PUMP' ITALLAT10 % / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK': • SEWER LINES 115 M-PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial -Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 3 inc <br /> Domestic/public Driven Gauge of Casing Class 160',-plastic <br /> Irrigation _. _ - ._ _.__ Gravel Pack Depth of Grout Seal 30 ft. <br /> _ Other "` Rotary Type of Grout Cement <br /> 1= <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor '"Ovmer <br /> Type of Pump 2- hp shallow well pump H.P. ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> kEST_R_UCTION 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 California pertaining to or regulating well construction. Within. FIFT.EEN 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY - DATE ����� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3-/f- 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />