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pp ter r. <br /> 3dj"-y.' 1 '•-•~ ?- 4 •'S ryt„+.Ik, - 'C4 -y t'+": _ :•t � ..;1 _4 <br /> fir✓.I aS +S ' "ri ` <br /> �� 5'Fw..s,� �.I Y >~a sl.-''-� =�rJa''?I"rlA�t. -- r s -.+..• L4w� <br /> � �.,+:.u� 7d Wil, � r ��S •aafa$�� + _ 1 _ .. 4,, <br /> t 4' .. - ,�''w,"'+. �.y-,wk `a' -1 •rc 'r' y`f �+, yiea�t•....�ne.,�i..«.i�.,..•�•st'^�-• "-x�• s'(ham <br /> Li <br /> ` SANT JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOh 0 ICE USE 1601 E. Hazelton Ave., Stockton, Calif. <br /> = Telephone: . (2 09) 466-6781 O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na Idr-6 <br /> ,EXPIRES'1 YEAR FROM DATE:-ISSUED Date Issued <br /> t . <br /> `t <br /> (Complete- In Triplicate) . 4 . <br /> Application is .hereby made':to the San Joaquin Local Health District:.for a''permit to const=ct�a` . <br /> and%or install 'the work'-herein described: This application is made in compliance with Ski,Joageiia <br /> S�Caunty Ordinance bio:`^1862 and',the'Rules' and Regulations of the San Joaquin Local Health Dfstrict' <br /> 9E .SES <br /> JO$`7lDbRBSS/LOCATION ���f _SC�-oN__ G,4 CENSUS'TRACT" <br /> Owner's Name #r lPhone ` ! <br /> CityS�l�cJ N :: <br /> Contractor�e Name �d'�lJ•�Y1r✓42,��6 � a��,g� C4 ".License .# Phone mi 6/i; Y <br /> C �TYPE'.yOF WORK (Check) NEW WELI;`/ DEEPEN 'I_7 RECONDITION /_7 DESTRt7C'i'ION :%T V r D;�+`�r s <br /> !" s PUMF,INSTALLATION / /. PUMP REPAIR'/ / PUMP REPLACEMENT �: _' T <br /> DIrTANCE TO NEAitEST SEPTIC;_TAMC SEWER.LINES ' PIS PRIVY . f <br /> SEWAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE.PIT .- <br /> OTHER c� ir1 <br /> PROPERTY LINE. •PRIVATE DOMESTIC.WELL 3hc PUBLIC DOMESTIC"WELL` `­ "^� <br /> ` ��:INTENDED'`.USE i TYPE OF'WELL CONSTRUCTION:SPECIFICATIONS-i—, <br /> .r�~':Industrial u r Cable Tool' Dia: of Well Excavation... <br /> Dames,tild private Dri]Ied Dia.,of Well Casing ��•• Y 3r� '� <br /> Domestic%public' Driven Gauge.of.Casing :��. - •F»� -:�? <br /> K' 4 ]fir Ixript.tioa f Gravel Pack Depth..,of Grout Seal <br /> s y . Cathoditc Protection _, 'Rotary Type of Grout y. ,4it ,+•: �.^ ,,� <br /> sposal ' a Other Other:Infarmation; <br /> +fc"*,=Geophysical Surface--Seal Installed-By: k <br /> d Y I <br /> OR "'.INSTALLATION Contractor ;y <br /> Type 6f Pump, <br /> ..F•+�-s.� - s A.-�-vco, <br /> �<PUMP REPLACEMENT L/ State Work Dunr_ <br /> aPState' Work -Done ¢, <br /> '�r'�a'Yrs-x,•�'`�..t- <br /> 1DES•TRUCTION.OF WELL Well. Diameter Approximate.Depth:' ••�•i- ti , <br /> y a Describe�Material and Procedure <br /> Ihereby'agreeti`ta comply with all ..laws and regulations of .the San Joaquin Local.Health Districts <br /> and`the State:o£ California pertaining to or regulating well••construction: Within',FXFTEEh�.MYS A <br /> �Afterrcomp:letion of my work'oa a,neso well, I .will furnish the San Joaquin'Local':Healtti DiatriCt�a <br /> �WELIwDRILLERSF REPORT yof the':well''and .notify them before putting.the well in use: The shoos° y <br /> information�iertrue to the best of..niy knowledge and belief.-.'1 I WILL:CALL":'FOR:A CROUT':INSPl;CTION <br /> aPAIOR=TO GRf}UTING ANDA F AL;:INSPECrION. <br /> $ SIGNED Y TITLE _ ,xP ; <br /> DRAW PLOT- PLAN ON REVERSE <br /> r <br /> FOR DEPARTMENT WE <br /> PHASE I <br /> VAPPLICATION;`ACCEPTED:BY <br /> ADDITIONAL,,COMMENTS :.. ' .. i <br /> s ^3` .. <br /> ` PHASE GROUT INSPECTION 3A+)—PHASE I FINAL INSPECTION sa <br /> rt INSPECTION BY K DATE : INSPECTION-f BY DATE <br /> .77 <br /> 426 b/77 21y <br /> QN, <br /> 12I-, <br />