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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r a4 Telephone: (209) 466-6781 <br /> Ft APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f,.,$_3� 4c <br /> ,,3-6 K <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sart 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. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4625 Homer CENSUS TRACT <br /> Owners blame Williwm Jac ober Phone 465 7979 <br /> Address 402 E. Geary City Stockton <br /> Contractors Name J. A. Thalhamer Co. License #272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /- DESTRUCTION /VT <br /> PUMP. INSTALLATION /i/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other r—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 5_2 �ft. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation nc p <br /> ** Domestic/private Drilled Dia. of Well Casing inch `V <br /> Domestic/public Driven Gauge of Casing ,109 C!� <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Other ** Rotary Type of Grout Cement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Universal Pump Cow <br /> Type of Pump Jacuzzi suEersible H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP. REPAIR: /% State Work Done _ <br /> ESTRUCTION OF WELL: Well Diameter 6 inch Approximate Depth 105 ft* <br /> Describe Material and Procedure C 1 ay to N ft. Cement to the top <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-aud 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 fell contractor <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FO TMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED B J .. Jr D <br /> ADDITIONAL CQMMENTS• <br /> COMMENTS.., <br /> PHAS .` OECTIONT <br /> ECTION PHA INSPECTION <br /> INSPECTION BY �. �_'� INSPECTION BY - DATE Z <br /> CALL FOR 1 RIOR TOGROUTING AND FINAL I C 4. 77 <br /> E H 14.26 7/72 1M <br />