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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y <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 4750 La orio Rd& CENSUS TRACT <br /> Owner's Name S. R. Steele Phone 931 1879 <br /> Address 47 La orio Rd. <br /> City Stockton <br /> Contractor's Name J. A. Thal er Coo, License #272 303 Phone477 1858 <br /> TYPE OF WORK (Check): NEW WELL /-T N /i* RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTAL ATI N / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T 82 rte SEWER LINES PIT PRIVY <br /> SEWAGE DI POS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 0 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool a of Well-Excavation 6 inch <br /> * Domestic/private Drilled D of Well Casing <br /> Domestic/public en u e of Casing d <br /> Irrigation Gravel Pack De h of Grout Seal <br /> Other * otary of Grout <br /> Other er Information Install 5 inch liner <br /> PUMP INSTALLA 0 Contr to al a o. <br /> \ Type of m s H.P. 8 <br /> PUMP REPLACEMENT: ' / / State Work Done I!Mll Pump, a en well reset Dump <br /> PUMP REPAIR: / / Sta a Work Done <br /> ,RESTRUCTION OF WELL: We is ter Approximate Depth <br /> Descr Material and Procedu <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 /> SIGNED , <br /> ^- TITLE� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I AR <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE eROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY &Z& DATE INSPECTION BY 10 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />