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SAN JOAQUIN LOCAL HEALTH DISTRICT ' l <br /> FOROFFICE USE: 111601 E. Hazelton Ave. , Stockton, Calif. <br /> if 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 ,7, 7 � <br /> 12-- -11 (Complete In Triplicate) ��✓ 2�5-�7©^eaF, <br /> Application is hereby made to the Satz 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. 3862 and the Rules d Regulations of the San Joaquin Local Health District.. <br /> ..ice <br /> JOB ADDRESS/LOCATION 2,000'; E. Dead End & 49000' S. River-load CENSUS TRACT <br /> I� <br /> Owner's Name M. & R. Zolezzl Phone <br /> Address --S- 17787 kYont StI:it:den, CaZsf. 95236 City <br /> Contractor's NameParviance Driii era P.O.Box 64 T,inden Calif. License # 21,.03.07 Phone' 931-41+68 <br /> i� 952 <br /> OF WORK (Check).- NEW- WELL /7 DEEPEN '`AT RECONDITION. /V_..AESfRU_CTi6N"'f7- <br /> TYPE <br /> r; PUMPi�INSTALI;ATION PLW REPAIR // -PUMP REPLACEMENT -Ixj`"` <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK ` Mi a SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4- Mile CESSPOOL/SEEPAGE PIT,? OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC-DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I x Cable Tool Dia. of Well Excavation eepen x s ing 121' We�j <br />` Domestic/private Drilled Dia. of Well Casing %& Inst. Linew <br /> Domestic/public I Driven Gauge of Casing <br /> g Irrigation I Gravel Pack Depth of Grout Seal. ! <br /> Cathodic Protection RotaryTyype..-of-Grout ---- r <br /> Disposal Other Other Information C F <br /> Geophysical Surface Seal'' Installed By: 1 <br /> I t ! <br /> PUMP INSTALLATION: Contractor T }. <br /> Type Pump of Pu 4 .Y H.P. <br /> PUMP REPLACEMENT., A-7 State Worle,Done Install existing-;40 HP <br /> k. <br /> / --_, PUMA' '.REPAIR:•, - <br /> . . . State. Work Done <br /> 4ES1RUCTION OF-WELL: --WelliDiameter Approximate Depth <br /> Describe Material and Procedure <br /> �- IL <br /> I hereby agree to comply with all' -laws and regulations of the San Joaquin Local Health District <br /> and the State of California 4,•.pextaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my workon '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 GROUTIN A FINAL INSPECTION. <br /> SIGNED '�-. `'� TITLE Partner <br /> u (DRAW PLOT.PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -. DATE .7 <br /> ADDITIONAL COMMENTS: 1z, il <br /> ` PHASE II GROUT INSPECTION PHASE I /FIN INSPECTION- <br /> INSPECTION BY ik DATE -INSPECTION B ° DATE Z- Z -7, <br /> �k • ' <br /> w <br /> ,� E H 1426 Rev. 1-74 I 1-74 2M <br />