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r� <br />�rr � <br /> SAN JOAQUIN. LOCAL HEALTH DISTRICT 13�3 � <br /> FOR OFFICE US E• �I 1601 E. Hazelton Ave., Stockton, Calif. pl�e <br /> Telephone: (209) 466-6781 <br /> - ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :7 3 -ag! W µ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �j (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�J0€ ;tiff <br /> County Ordinance No. 18b2 and the Rules and Regulations of the San Joaquin Local HeA6 Distr3.ct <br /> .FOB ADDRESS/LOCATION 2733 5• Airport Hay CENSUS TRACT <br /> Owner's Name delen Cerri Phone 982 4865 <br /> a <br /> Address 2732/ S• Airport Way City Stockton tirr <br /> J. A. Thalhamer Co. 272 x03 477 18558 <br /> Contractor s Name License B ' Phone „_,_ <br /> ME OF WORK (Check): NEW WELL ADEEPLI / RECONDITION /-7 DESTRUCTION /7 <br /> F 4 r <br /> PTW INSTALLATION /-J-PUMPREPAIR /-7—PUMP REPLACEMENT I? <br /> Other /-7 t <br /> _ Jti Y i <br /> DISTANCL TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY aT Y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT lWft• OTHER is <br /> INTENDED USE TYPE OF WELL CONSi•AUCTION SPECIFICATIONS t .a <br /> s Industrial Cable Tool Dia. of Well Excavation 10 inch <br /> s Domestic/private Drilled Dia. of Well Casing75 no <br /> Domestic/public Driven Gauge of Casing . <br /> i ft <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type of Grout amen <br /> Other Other Information y <br /> PUMP INSTALLATION: Contractor Moorman 'Dater Systems <br /> Type of Pump narnes submersAble H.P. _ 4✓ r <br /> Pugs REPLACEMENT: / // State Work Done 4-7 <br /> f <br /> PUMP REPAIR: / / :Mate Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth r xse' <br /> Describe Haterial and Procedure r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r, y <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN bAY5 s 7 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Dietritt a ° <br /> WELT, DRILLERS REPORT of ne well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. Y ' <br /> SIGNED + TI1LE sr <br /> DRAW PLOT PLAN ON REVERSE SI <br /> I <br /> FOR DEPARTMENT USE ONLY ~'~ <br /> 3 PHASE I <br />` APPLICATION ACCEPTED BY 4,- DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE III/FINAL INSPECT <br /> DATE f.-I 7� INSPECTION BY DATE <br /> IIMSPECTION BY 't <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 M �� t <br /> 4 <br /> cMs xn t� S'L"f i R� <br /> 1 /1 <br />