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SAN JOAQUIN LOCAL 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. 73-252 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 7 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 4523 'S. .Inland Drive CENSUS TRACT <br /> Owner's Name Ed-IVierra Phone 465 1146 <br /> Address 1523 S. Inland Drive City Stockton <br /> Contractor's Name J. A. Thalhame-r Co. License # 272 303 Phone 477 185 <br /> TYPE OF WORK (Check): <br /> NEW WELL /;-/ P DEEPEN/_7 RECONDITION� /'7 DESTRUCTION <br /> -PUMP-IDISTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> !: Other /% -- <br /> f � <br /> DISTANCE TO NEAREST: SEPTIC :TANK-1 7 SEWER LINES * PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation inc <br /> Domestic/private '.Drilled Dia, of Well Casing enc <br /> Domestic/pubiicDriven Gauge of Casing .Class 200 plastic <br /> Irrigation - Grave-1-Pack Depth of`Grout Seal P-5. fto <br /> Other Rotary Type of Grout Cement <br /> i Other Other Information <br /> s <br /> PUMP INSTALLATIONS Contractor Arc Pump Coe , <br /> Type of Pump Shallow well centrifugal H.P. <br /> PUMP REPLACEMENT: / 7 State Work Done <br /> PUMP-REPAIR, «-State-Work <br /> ESTRUCTION OF WELL: Well Diameter - ---- Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall 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 /> SIGNED 1 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> gZLV <br /> PHASE I FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BYWW DATE <br /> ADDITIONAL COMMENTS: a I <br /> PHASE II GROUT INSPECTION PHASE-JJI/FINAW INSPECTION <br /> INSPECTION BY DATE INSPECTION BYf� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 t 7/72 1M <br />