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SAN4-JOAQV- IN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <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 117Ao <br /> H'wa cor. Live Oak CENSUS TRACT <br /> Owner's Name L. Case <br /> Phone X66 O26 <br /> Address <br /> t -9 City Stockton <br /> Contractor's Name J. A. T'halhamer Co. License # 2720 4 <br /> 3 3 Phone 77 1858 <br /> TYPIC OF WORK (Check) : NEW WELL A_*T DEEPEN /'7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR 07 7PUMF REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKI.3 ft. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> ._ Industrial Cable Tool t' Dia, of-Well� Excavation 10 inch <br /> _ Domestic/private Drilled Dia. of Well Casing inch <br /> * Domestic/public Driven Gauge of Casing log �! <br /> Irrigation Gravel Pack Depth of Grout Seal0 ft. plus <br /> Other '�'� Rotary Type of Grout ement <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 Uj <br /> Lt� <br /> (DRAW PLOT PLAN ON REVERSET �7'rSID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE .3 f /7 <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _42 �_ DATE F -� INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />