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SAN JOAQUIN LOCAL HEALTH DISTRICT w <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> W Telephone: (209):i466-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. T�� <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 /> JOB ADDRESS/LOCATION 3211- Holt Rd. Holt CENSUS TRACT <br /> Owner's Name " Conrad Silva Phone 463 80o4 <br /> Address 1431 W. Walnut City Stockton <br /> Contractor's Name Je A. Thalhamer Co. License #272 303 Phone477 1858 � <br /> TYPE OF WORK (Check): NEW WELL 0*7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 86 Tt. SEWER LINES PIT PRIVY dM <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7 inch <br /> Domestic/private Drilled Dia. of Well Casing 3 inch, plastic <br /> Domestic/public Driven -' Gauge of Casing Class 200 <br /> Irrigation Gravel Pack Depth of Grout Seal 25 ft. <br /> Other ** Rotary Type of Grout Cement <br /> armor camp Other Other Information -- <br /> PUMP INSTAtI:ATIOki Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT., / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth �4 <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 i <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. r <br /> SIGNED TITLE!iU _ <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 INSPECT ON <br /> INSPECTION BY e'--glaaa DATE -z 7 INSPECTION BY f-•& DATE Z <br /> CALL FOR A GROUT SPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />