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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7rGS0.1-1' <br /> THIS PERMIT EXPIRES 1 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 wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .708 ADDRESS/LOCATION East side of TracyBl-'vd; North of Lehmann; across CENSUS TRACT <br /> rom Tracy <br /> Ownerts Nam A. Teichert & Son, Inc. Phone 209/$35/4931 <br /> Address. S.-MacArthur Drive City Tracy, CA <br /> Contractorts Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> TYPE OF WORK (Check): NEW WELLT7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR AF PUMP REPLACEMENT /7 <br /> Other L1 Clean Well <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 Drilled 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 i <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type -of Pump Rep. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: IXY State Work Done Clean Well. and Pumj1;i7Zepair <br /> 29STRUCTION OF WELL: Well Diamter 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 not y them before putting..the. well in.use.. The above <br /> .information is true to the-beat of my.kn edge and belief. I WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR M GROU A FINAL I SPECTION. <br /> SIGNED TITLE President <br /> (D PLOT PLAN ON REVERSE SIDE) ? <br /> FOR DEPARTMENT USE ONLY <br /> `PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 . Rev. 1-74 1-74 2M <br />