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LrJli , / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. o g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 /> '.tom w <br /> l W: corner Victoria Island on Old River <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name John F. Marcucci Phone 462 5997 <br /> Address 11525 S. Crocker Rd. City Stockton <br /> Contr'actor's Name J. A. Thalhamer Co. License # 272 503 Phone477 1858 <br /> TYPE OF WORK (Check): NEW WELL /+r// DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 g , <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other — <br /> a <br /> Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ft. PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 - <br /> Domestic/private Drilled Dia. of Well Casingg 22 anc p as zc <br /> Domestic/public Driven Gauge of Casing 16016. plastic <br /> Irrigation Gravel Pack Depth of Grout Seal Min. it. <br /> Other - Rotary Type of Grout Cement ` <br /> Other Other Information rN�.� <br /> PUMP INSTALLATION: Contractor I� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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. <br /> SIGNED TITLE' � � wt <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHAS I GRO T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />