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k 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.: 1601 E. Hazeltori Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 5 <br /> i <br /> THIS PERMIT EXPIRES 1°.YEAR FROM' <br /> DATE 'ISSUED DateTlssued :� Z, 7? <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 c6mpliance '%aith San Joaquin <br /> County Ordinance No. 1862' arid° the Rules ,and Regulations of the San Joaquin Locals Health District. <br /> t <br /> JOB ADDRESS/LOCATION �011_ Waller Rd. CENSUS TRACT <br /> c' {: -- <br /> Owner's Maine W: F. Fields t Phone A62 .7245 <br /> Address .527 E. Jacksom St« City Stockton: <br /> Contractor's Name_ J. A. Thelhamer 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 /> R Other / ./ <br /> DISTANCE TO NEAREST: SEPTIC TANK 78 SEWER LINES PIT PRIVY <br /> SEWAGE:DISPQSAL_FIELD_- , _- ,CESSP-0OI/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 'OF WELL CONSTRUCTION SPECIFICATIONS Y <br /> Industrial . r . Cable Tool, Dia. of Well Excavation 10 inch <br /> E *'� Domestic/private t 'Drilled - Dia, of -Well Casing 6 inch <br /> Domestic/public I Driven Gauge of Casing ,1Q <br /> Irrigation 1 (Gravel Pack= Depth of Grout Seal 0 ft, <br /> Other ** Rotary �L.jype of Grouts Cement <br /> -;Other Other InformationAz <br /> jD <br /> l <br /> PUMP INSTALLATION: Contractor ± r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: S ate Wor_ � Trk y <br /> `7bonene <br /> PUMP REPAIR: <br /> State Work Done <br /> F <br />,DESTRUCTION OF WELL: ., Well Diameter / �,GG� --w --*�R Approximate Depth rj-6.ir�_ <br /> eDescr.ibe Material and Procedure " <br /> 2.6- - Gc c rt t t'v_ To 43 . <br /> i hereby agree to comply with 'all laws and regulatioris. 6�f 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 oxi a new well, I will furnish the San Joaquin Local Health District a I <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 /> SIGNEDY i. <br /> �b'"� � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY O HATE z 9 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT-INSPECTION--, PHASE III/FINAL INSPECTION <br /> INSPECTION BY ITE _ 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION'PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 lM <br />