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. t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAiOFFI.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1-'f G✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L,22-77 <br /> (Complete In Triplicate) .2-%(0 Oeb--o <br /> Application is hereby made to the San Joaquin Local Health Disttict 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 /> ;TOB ADDRESS/LOCATION North east corner Lammers and Valpico CENSUS TRACT <br /> Owner's Name John Zambetti Phone 248-1507 <br /> Address 1401 Los Padres Boulevard City . Santa Clara, CA <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295.4332 <br /> W <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/—[ RECONDITION XV DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR XV—PUMP REPLACEMENT <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 rt <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casingi <br /> Domestic/public Driven ,,t Gauge of Casing ' <br /> 'riR- at!on 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: j/ / State Work Done <br /> PUMP ?REPAIR: State Work.Done Reaonditton Well and Pamp Repair <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure k <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 t <br /> information is true to the-best."y knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOIJ <br /> PRIOR T GROWI; D A FINAL IN PE ION. + <br /> SIGNS TITLE President <br /> DRAW PLOT PLAN ON REVERSE SIDE ; <br /> FOR DEPARTWT USE ONLY j <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATES— �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROIN INSP CTION PHASE I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />