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r.••r - rr-: �y. <br /> 2`; r- -.{! ,:•k1 ems;;,, -,. - - F ? _ - -�'�. <br /> ��ry rese .Sr _ .♦ <br /> - '-� 7-: _+�. ✓. F`;f'�,"'�t�'..b':s`.�er,""?r-:�at•...e +..:ru>rF+b�y,, r t t+.. <br /> fSAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOPi_OF�FICE USE. 1601 E. Hazelton Ave., Stockton, Calit. <br /> Telephone:` (209) 466-6781 <br /> APPLICnTION FOIL WELL CONSTRUCTION OR PUMP PERMIT Permit. No.-— + <br /> : THIS 'PERMIT EXPIRES 1 YEAR FROM--DATE'ISSUED Bate`.Issued. 4'/�7 J <br /> (Complete In Triplicate) <br /> Application is :hereby made to the San Joaquin Local Health District for a permit to coastruct,��'`,� , <br /> and%or install 'the 'work he u-described.. This application is made in"compliance wi•th`San Joaquin • <br /> County, Ordinance'Noand Rules and Regulations of the San:Joiq'ui'n Local HeaTth:D strict <br /> V 5EG/4: t <br /> I.NB ADDRESS/LOCATION 3 C CENSUS'TRACT' <br /> 1 Owner's Nam ..r Phone�,,:y# .r <br /> _ <br /> A <br /> City. <br /> ddress <br /> Iyfr•a - - - <br /> v <br /> Contractor's Name License Phone o <br /> f �i ;7 .1 i <br /> TYPE QF WORK (Check) NEW WELL /�rDEEPEIV/7 RECONDITION 17 DESTRUCTION <br /> PUMP. INSTALLATION / /. PUMP REPAIR / / ' PiIMP.'REPLACEMENT . <br /> �. — <br /> r <br /> Other L/ 77 <br /> DISTANCE TOsNBAREST SEPTIC TANK 9C SEWER LINES IIT PRIVY-'-- r <br /> SEWAGE.DISPC3AL'FIELD ' .CESSPOOL/SEE_PAGE.PIT . QTHER <br /> r ".r PRQPERTY-LINFr:W PRIVATE DOMESTIC WELL '`PUBLIC".DOMESTrC WELT!:•-' <br /> INTENDED'-USE -TYPE OF .WELL CONSTRUCTION-.SPECIFICATIONS 4.,i <br /> as Iadustrial� Cable Tool Dia: of Well-'Excavation­-.-­:, <br /> Domestic/private Drilled Dia. of Well Casfng <br /> OMP-1 <br /> t' Domstic/public Driven Gauge of Casing'.'-1. <br /> L Irrigation" .Gravel Pack` Depthof: Grnut Seal v i <br /> Cathodic Protection x Rotary. Type of Grout k <br /> Disposal Other Other'Information,; <br /> s Geophyaical Surface Seal-'I'stalled BY: <br /> t'' <br /> 7 <br /> .,PUMP INSTALLATION Contractor .A �`r a {L? <br /> "Type.-of of P <br /> � ump <br /> 'PUMP REPLACEi�+NT. / / State Work Done -• "`� •.�„a <br /> PUMP REPAIR :State Work Dane <br /> -',-DES CTION OF WELL nell. Diamete` <br /> �. _ Approximate Depth `a <br /> s� escribe Material and Procedure <br /> hereby agree to comply with all ,laws sand reguiLtions of the San Joaquin._Local ,Health District <br /> ;and the Sfatc of`Galifornta; oertaininB to-or regulating well'cnstrudtion'.`.-: <br /> r Vthin FIFTEEN,DAYSti <br /> z of ter, completion of my waric on a new well, I will furnish.th Sap 1644uin`Lodai`•Health:District8.� <br /> WELL DRILLERS REPORT a h �: <br /> f the well.and notify them before putting the.:well'in rise::. The'�'above E`-, . <br /> tiinformaCfoa is .true to the, best of-my knowledge and belief,T I'WILL'CAT.L-4bR A GROUT INSPECTION : <br /> PRIOR:TO GROUTING AND 'A .FIN INS <br /> LECTION. <br /> SIGNED <br /> :, r <br /> TITLE.- 1.sY��,t� <br /> DRAW.PLOT.PLAN ON REVERSE;S IDE <br /> FOR DEPARTMENT USE ONLY Y <br /> s PHASE` I Y <br /> !J'PLICATION.ACCEPTED BY '►\ DATE <br /> ` ADDITIONAL COMMEt:TS ." :' ... - , <br /> PHASE II .GROU INSPECTION PHASE 'III FINAL INSPECTION <br /> INSPECTION'BY DATE INSPECTION BY <br /> DATE_ O 7-• r ,, ;y <br /> E.H "1k25 Re _ 6/77 <br /> r��,iyy{•.• �y1`� c^/.n?.- '"4f} p, p ,5 � Y'r J h� - _. ,�` _�,.� r i `tf -- T' j �{ <br /> u- iW�Y 'i3 '{i 11B-1 f - <br /> . . st aa,; �t ,• f <br />