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3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE'�i�SE: 1601 E. Hazelton'Ave. '.:.Sfockton, Calif. <br /> ' ` Telephone:r..,,(209) A6616781 <br /> APPLICATION FOR WELL CONSTRUCTIONi OR PUMP PERMIT Permit No. Z Z� <br /> THIS PERMIT?EKPIRES-1 A.YEAR*FROM=DATE 'ISSUED':_' Date Issued ZL�-7 7/� <br /> . .10 03,:.,(Complete Tfi�,Tri,plicate) <br /> Applicati'.onZis;hereby•,made-.to therSan�Joaqui-n'Laca'1 Health District o.fgr .a-.permit^ to construct' .4 <br /> , and/or install the work herein described. Thisa`application is ,made .'in compliance with. San Joaquin <br /> County-OrdinanceNo.,71562:.arid;rhef,'Rules a.nd!7Regulati:ons., 'f'the,San .Joaquin.Local`•Health District.. <br /> t 1.,,80g3.��.;� �'.1 - <br /> JOB ADDRESS/LOCATION f��% �C a „,,.CENSUS -TRACT <br /> Tkr#baa r3nirr t:Y� J� 13u C4 d:s i�L � ._.ani..., L <br /> Ownerrs:kNameOz r .F-' *- -s3 1st :oxq i,,ntt:::`.�-[bn >_o r <br /> YJer, CAS : <br /> Address <br /> Contractors Name ense �0Phone $ Y, -03;P <br /> TYPE OF WORK (Check) : NEW WELL /X/- DEEPEN �/ RECONDITION / ?/ DESTRUCTION /-7 <br /> PUMPIINSTALLATION 0 PUMP REPAIR/ / 1PUMP REPLACEMENT /? <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK 570 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ,FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> { INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> ' .. } Cable Tool Dia. of Well Excavation 47 <br /> VDomestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information l,'^ O <br /> ---- <br /> PUMP INSTALLATION; Contractor <br /> Type ;of Pump a� # t H.P. <br /> PUMP REPLACEMENT: `S W Y r" <br />' / / State Work"Done ; ,-,y � <br />