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A y <br /> -4ke <br /> SAN JOAQUIN I,056L HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. G <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,// _ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -73 I <br /> (Complete In Triplicate) ,. <br /> Application is hereby made td the San Joaquin Local health District for a permit to construct G <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 2862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 12152 IN'.LVIR.SAC.RD. CENSUS TRACT <br /> Owner's Nage SAID-FU?.INAtk Phone 3683595 <br /> Address 12152 N.LWR.SAC.RD. City Edi <br /> ASHLEY THALHAMER <br /> Contractor's Name License Phoney/71 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITI_ON /_7 DESTRUCTION /7 <br /> z .,... PUMP-:�-INSTALLATION%/-SPUME'REPAIR <br /> Other <br /> Replace exisstinF_ unit_ <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANS: SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial J Cable Tool Dia. of Well Excavation . + <br /> — Domestic/private t Drilled Dia. of Well Casing 6111N <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ,1 Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout ' <br /> t Other Other Information "s <br /> N <br /> PUMP INSTALLATION: Contractor _ AMh1eY Thalhamer -- <br /> Type of Pump --Submersible H.P. 2H.? 1 <br /> _ N <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUMP REPAIR: / / State Work Done <br />_.,pESTRUCT'ION_OF__WELLtWell�Diame.ter: = �Approximate­Depth� <br /> Describe Material and Procedure 1 j <br /> fes` <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 r G1 TITLE djt,�"_ <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> / FOR DEPARTMENT USE ONLY t <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE.- _._. .INSPECTION BY. DATE <br /> r CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 9 H 1426 "` 7/72 1M <br />