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(IAN JOAQUIN .LOCAL HEALTH DISTRICT`'' <br /> _ � <br /> D <br /> FOAiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7y7f4�' � <br /> Telephone. (209) 466-6781 C 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.7-6 <br /> W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued -6-,?>­77 <br /> l <br /> (Complete In Triplicate) -z-`(4- 0evr'0/ I <br /> Application is hereby made to the San Joaquin Local Health District for a permit .to construct 111. <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Couaty�Ordinance No._,1862_,and the Rules and Regulations of the San Soaguin Local Health District. <br /> COV <br /> CENSUS TRACT <br /> ;308 ADDRESS/LOCATION 16orth east corner Lamers and Yalpico <br /> Owner's Name John Za:nbetti Phone 248-1547 <br /> Address <br /> 1401 Los Padres Boulevard City . Santa Clara, CA <br /> Contractorfs Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> W <br /> TYPE OF WORK (Check): NEW WELL ,/_7 DEEPENI 7 RECONDITION P7 DESTRUCTION <br /> PUMP INSTALLATION J I PUMP REPAIR XV—PUMP REPLACEMENT /7 <br /> Other / / ; <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 t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � �I <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ? <br /> Domestic/public. Driven Gauge of Casing <br /> "�zri'gat3t►:i �`� '� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Install.ed_,By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work,Done Recondition hell and Pump Repair <br /> PES-T UCTION OF WELL: Well Diameter Approximate Depth <br /> Describd 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_,,, <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• - y.knowledge and belief. I WILL CALL FORA-GROUT INSPECTIO <br /> PRIOR IR GRD I D A FINAL IN PE ION. <br /> SIGN TITLE President <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPART!MT__USE ONLY J <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ! <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION PHASE I F NAL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE <br /> I E H 1426 Rev. 1-74 1-74 2M <br />