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L /eh? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T1Z. Yo <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued ,2--.- <br /> h (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 <br /> 1 Flower St. �~ CENSUS TRACT <br /> Owner's Name H. E. Looper Phone 462 88 <br /> 55 <br /> Address 9 1 Flower St.. � <br /> . City <br /> Contractor's Name J. A. Thalharmer Co. License #272 N3 Phone 477 .1858 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN jW RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 62- ft. SEWER LINES 72 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 <br /> Domestic/private Drilled Dia. of Well Casing 5 inch O.D. <br /> Domestic/public Driven Gauge of Casing �+ <br /> Irrigation -- -.- r _ Gravel Pack Depth of Grout Seal ' <br /> Other ' * Rotary Type of Grout j Ye <br /> Other Other Information <br /> Y � <br /> PUMP INSTALLATIONS Contractor Owner <br /> Type of Pump x Jacmzzi submersible, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:. / / ., State Work Dne <br /> ESTRUCTION 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*/eaell - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - F <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE a- 19 °]q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I I FINAL INSPE TI <br /> .. O ' <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M e <br />