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`�- <br /> +. ��s•-��x•�,n r',��" ._._ .. -r.._ .- ...� y- _. T��+i•'w•ic'n'oy,,'..+ v -...- „,.-r+.—.'..xx .-q.C,«HC ti.::: - �i. - 'r„r,-„..»...-."u _ <br /> 'S'ej.1w;'e_4AN .'•OAQUIN LOCAL HEALTH DISTRICT <br /> ,FOF�:OFFICE USE 1601 E. Hazelton Ave. Stockton Calif. * <br /> Telephone: (209),466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'-7 <br /> 777 <br /> THIS PERMIT MIRES 1 YEAR FROM DATE ISSUID Date Issuedr <br /> 7, a. <br /> s� .a (Complete In,Triplicate) ­,.' uc M1 <br /> f <br /> Application ie.hereby made to-the”,5an'.Joaquin Local Health Distriet for permit to,conatftct <br /> d/or install`_the Work herein described This application ie 'made iri compliadce;with. San•.Joaquin <br /> CouatyrOrdinance No 1862 and ttie Rules snd Regulations of the Sin "Joaquin Local Health District <br /> OE,ADDRESS/LOCATION10 LEL �ENSUS <br /> Phone .: <br /> ' r <br /> ti�reas - : <br /> ' rY j.• - 4/1 City:' tee.v <br /> ion"tractor s Nasse License P y�nf <br /> honeµ <br /> ?YPEOF�WORK (Chec(c) r N� :DEEPEN'`/ RECONDITION /� :.DESTRUCTION. �] �a' <br /> K *�5 yy PU[+� INSTALLATION L�. PUMP REPAIR /� PUMF.REPLACEMENT <br /> DI$TANCEzTO NEAREST SEPTIC TANK' ' <br /> SEW$R LINES.::.' � •' PIT PRIVY,. <br /> '� A � E _.SEWAGE..DISPOSAL PIELD'r- 'CSPOOL/SEEPA <br /> ESGE'PIT OTIIBR :'- 'J i <br /> PROPERTY'LIN .PRIVATE DOMESTIC WELLS1f1&� PUBLIC DOMESTIC•WELjrt <br /> T <br /> a ''�'� INTENDED�US$ -� TYP :OF-WELL CONSTRUCTION. SPECIFICATIONS' k <br /> Industrial Cable Tool Dia.: of We'_.I Excavation ,�� r:'. ry <br /> 16 � <br /> Domestic/Private } Drilled Dia:' of Well "Geeing 44, •�F t� �s+'.�:. <br /> ometiDriven auge of:Casin <br /> + - Irrigation �, h Gravel Pack Depth'of. Grout 5ea1 _ ja <br /> ° ` �F Cathodic Protection a Rotary Type' of Grout �. . r. w <br /> Dispoael � , Other "other'Information <br /> c t�� <br /> Ceoptsysi al4 Surface Seal Installed By. .�-•- yk <br /> +PU!lPINSTALLATION:� { Contractor, <br /> e of Psi <br /> t,Cy rs YP , i mP H.P c�� s�tzcsj„ <br /> ��' REPLACE?�NT:° `� tatsti c <br /> .:Workw. <br /> tU4 <br /> .It r�'tilP:q�I� h <br /> �PDlO' REPAYR•�y� 3 State Work Done." <br /> ��..�rrYyrrrr_ 2f7 p � t�IlYw. 4�� <br /> 7y <br /> , <br /> yPESTRUCTION OF WELL " Weli'Diametei Approximate <br /> Describe Material and Procedure: <br /> y Thereby agree to c0mp1y,w1th awl laws and regulations of the•San.Joaquin•.Locall:Health;-.:Distriet <br /> and�the4Sxste ffo"fMalifornia pertaining to or .regulating wall construction: Within FIFTE$N'DAY$i. <br /> er rC0 le't r r,. <br /> ""���iop,w ois of piny work:ants .aew•well, I,mil furnish.the: San Joaquin.Local HealtEi Distiict�•a' <br /> DRILLEEESREFORTof the,well°end-notify,them:before putting the well;in use:; Zue�above :` " <br /> inorsn"stiost trueto the`b t` f y owledge and belief I WILL CALLkFORA GROUT ,INSPHCTIONs <br /> PRIOR' G -:A FIN P O <br /> BIGNEDt n r ,4r TITLE <br /> AA <br /> DRAW PLOT PLAN ON REVERSE .SIDE j r:•-o?!s ^; ' <br /> p,rE`Z 7, w FOR.DEPARTMENT.USE ONLY <br /> APPLICATION-ACCEPTED -BY 'Z <br /> DATE <br /> ADDITIQiZAL COI�NTS s ,' a : ." ,. <br /> PHASE II GROUT=INSPECTION ' �,~ PHASE III FINAL INSFECTZON :-•c��•r <br /> INSPECTION BY DATE INSPECTION BY �iJ -DATE S"/ <br /> . +, r ' rt Tz <br /> E:H.1425. Rev. 2 �t;g= <br /> r .xy <br /> V' 7w4r� kr ,� •~W { ]t'' �, r s tih y i1 sr eF v 1 y f -... •� ...�.- <br /> r�—t�,h <br /> 1 7 <br /> A , <br />