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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-!y 9e <br /> THIS PERMIT EXPIRES 'l 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 /> V. � <br /> JOB ADDRESS/LOCATION 8283 E. nest Ripon Rd. CENSUS TRACT <br /> Owner's Name Robert Sobrero7 823 4503 <br /> Phone <br /> Address 8283 E. '4est Ripon Rd. City MgAf Ripon. <br /> Contractor's Name J. A. Thalhamer Coo License # 272 303 Phone 77 1858 <br /> TYPE OF WORK (Check) : NEW WELL / ] DEEPEN /_% +RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / �....,._,..h T — <br /> DISTANCE TO NEAREST:- ,°`SEPTIC TANK50 - t. SEWER LINES 60 F • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- - - CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED SE TYPE OF WE CONSTRU TION SPECIFICATIONS <br /> jDome <br /> s tri l XD <br /> Tool —Dia: --Well " ccavati.on (" <br /> * st /private. led Dia. o Wel Casin wf <br /> is ;- ---- g --- <br /> /pub]ir. en GAInfor <br /> ng <br /> gationel Pack Dt Seal <br /> r <br /> ry T <br /> vr' 0tion <br /> PUMP INSTALLATION: ` 'Contractor r J <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: / / State Work Ione <br />-PUMP__REPAIR.., x =rSta•t �Wo k::,Dane �' ' <br /> - <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 truer too the best of my knowledge and belief. <br /> SIGNED TITLEL'U�:L C' <br /> i <br /> �l-4L CII.��u,.r. L ` <br /> mac, <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C &5V . - _ TE <br /> ADDITIONAL COMMENTS: 0 4v <br /> P . 5P N P �II ��JNSPECZION k <br /> INSPECTION BY �~ INSPECT BX DATE <br /> CALL FOR A GROUT INSPECTION..PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />