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f 1 <br /> - i SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> t09P'ICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> . 7�1G3� <br /> IS PERMIT EXPIRES 1 YEAR MOM DATE ISSUED Date Issued, <br /> 4t 2 ' - kiV1E.0-.Q4 (Complete In Triplicate) �✓ , 2-y-.5-2-70-U&Application is hereby made o the San Joaquin Local 'Health District for a permit to construct f <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 aad the Rules d Regulations of the San Joaquin Local Health District.. <br /> a " d End & 4,000 S. River-`load <br /> JOB ADDRESS/LOCATION 2fOQ(}'1 E. ' CENSUS TRACT . <br /> Owner's Name N. & R. Zolazzi _ <br /> _ Phone <br /> Address 17787 E 14ont St 11nden CaI ..95236 City .y <br /> Contractdr'a N n r1iere P.O.Box Linden Calif. License # <br /> 248107 Phone' 931-4/0 <br /> 9523b <br /> TYPE OF,WORK (Check): NEW LL /7 DEEPEN '. CONDITION_ /V. DES.iCTION!f-7- -.. _. .--.-.. .. <br /> - Ti) Ii4SSi L-ATIOAI-L .PUMP" REPAIR /7 .PUMP REPLACmMff R <br /> Other C7 K- <br /> DISTANCE TO NEAREST: SEPTIC TANK X a SEWER LINES PIT PRIVY <br /> SEWAG�3 DISPOSAL FIELD -4• M Is CESSPOOL/SEEPAGE PIT,' y OTHER <br /> PROPERV LINE - PRIVATE DOMESTIC WELL' PUBLIC.WMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial X Cable Tool Dia. of Well. Excavation eepen a ing 1211 Wi1e11 <br /> Domestic/private Drilled Dia. of Well Casing %& n eV <br /> Domestic/public Driven —AllGauge of Casing _ <br /> % Irrigation Gravel Pack Depth of Grout Seal _^ ""• �� <br /> Cathodic Protection Rotary_ .-Type---of-Grout, <br /> Disposal Other Other Infdrmation. <br /> Geophysical 'Surface Seal' Ia tailed Bg: sIn ` <br /> PUMP INSTALLATION: � k f <br /> C4ntFaCtOr <br /> Type of Pump H.P. <br /> jj <br /> PUMP REPLACEMENT: A/ State%Work,Done IndtaZY e�deting,/,O ffi ti �J <br /> i <br /> PU�+l1''�1tEPAIR <br /> �_. . .•� L7.L State Work Done <br /> ES1RUCTION Ok-WELL: --Well; Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 5 I hereby agree to comply with all'-laws and regulations of the San Joagitiu' 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 notiiy..,them before <br /> putting. the .well in-use.. The above <br /> information is true to the•6est-of- i!ky"knowled'geand belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> PRIOR TO GROUTIN A FINAL INSPECTION. <br /> SIGNED ~ TITLE Partner, <br /> DRAW PLOIT.giM ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY _ <br /> • � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> _PHASE II GROUT, INSPECTION PHASE I F INSPECTION. <br /> INSPECTION BY I DATE - /VINSPECTION- DATE 2- 7---7& <br /> E H 1426 Rev. .I-74 • <br /> ___ - 1-74 2M <br />