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kv 4 <br /> ` B SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USEVI 1601, E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> JOB ADDRESS/LOCATION Camp 1, Woodward Island CENSUS TRACT <br /> Owner's Name Conrad Silva Phone 463 8004 <br /> Address 1431 W. Walnut St. City Stockton <br /> Contractor's Name J,, A. Thalhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION 1-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ •SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 0 <br /> Q-- <br /> INTENDED USE TYPE OF WELL- - - CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation 7.Tsc <br /> * Domestic/private Drilled Dia, of Well Casing • inc <br /> Domestic/public Driven Gauge of Casing Class 200 <br /> Irrigation Gravel Pack Depth of Grout Seal _ i't. VA <br /> Rotary Other � -- <br /> Type of Grout Cement � <br /> i` Other Other Information <br /> a., <br /> PUMP INSTALLATION: Contractor Owner I <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> E / / State Work Done <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 th_e 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 /> J 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 /> � <br /> SIGNED `r _ � TITLEC/ 44,e t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �;. - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDIfIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. s1 <br /> E H 1426 <br /> 7/72 1M <br />