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SAN JOAQUIN LOCAL HEALTH.DISTRICT R <br /> FOE`OFFI�E <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .27-2 <br /> 3 P <br /> ( THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued 6 -7, <br /> (}v (Complete In Triplicate) <br /> Application is 4hereby 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 11T QCI E16 jaulei2 Shc7 ) 2U CENSUS TRACT <br /> Owner's Name 'e A" ZAUCAIZA W4 Phone <br /> Address A60 67, /I4&1_1 Zie-0,0 le 42 City LdU <br /> San Joaquin Pump Ca 2� <br /> Contractor's Namec,inh„r CQJ License # hone <br /> ar•5eu�ea�l.,,�•,y <br /> 233 11 Z St. i <br /> a #a.rr+ia 9524 <br /> TYPE OF WORK (Check) : NEW WELL 71 DEEPEN '/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR J / PUMP REPLACEMENT <br /> O they <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable`-Tool Dia. of Well Excavation <br /> Domestic/private Dr-filled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing : <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection- Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L State Work Done cT,,q/` /(> /ho <br /> PUMP .REPAIR: / / State Work Done <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 true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE San Joaquin Pump CO. <br /> W PLAN 'ON SE SIDE d . :�; , <br /> FOR DEPARTMENT USE ONLY Cal;farnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY f7(' DATEl�'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I117ME INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-Z'7--97 <br />- 3/76 ZK <br /> H 1426 Rev. 1-74 <br />