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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T-A� -33 <br /> (Complete In Triplicate) <br /> Application is hereby de 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 1055 White bane CENSUS TRACT <br /> Owner's Name Allan Rosasco Phone 931 2199 <br /> Address 1055 White Lan® City Stockton <br /> Contractor's Name J. A. Thalhamer Co. License #272 _303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /_7 DESTRUCTION. /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / J T — <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 i't. SEWER LINES 71 ft. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia, of Well Excavation 0 inch— <br /> Domestic/private <br /> nc Domestic/private Drilled Dia. of Well Casing 6 inc zner <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Lone <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Niaorman Water Systems <br /> Type of Pump ernes su mersz a H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: / J State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. �, f <br /> SIGNED TITLE)IJCd <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJIFASAL INSPECTION > <br /> INSPECTION BY DATE INSPECTION BY DATE -, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TIO . <br /> E H 1426 7/72 1M <br />