|
i' �Y+ •d:' - _ .., '---'-e.,,.-.... -.�...��..u... ..� .. a ... ,a
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> a ;FOR'..OFFICE.USE: 1601 E. Hazelton Ave., Stockton, Calif. <
<br /> Telephone: (209) 466-6781
<br /> .: � ICATION FOR WELL- CONSTRUCTION'OR PUMP PERMIT Permit No. �'S
<br /> -
<br /> i HIS 'PERMIT EXPIRES '1'YEAR FROM DATE ISSUED '7Date Issued ( 1 7yk
<br /> ,Inx (Complete In• Triplicate) f,
<br /> Application is hereby:made_to' thee San'Joaquin'Local Health District.-for a permit to construct , , ,,,_.
<br /> .
<br /> �.atid/or;installthe:Work:,hereia-described: ,_ This application is:made':iacomplianca..r�ith SaaaJoaquing.
<br /> -County Ordinanae`Na 1862 ind,the Rules and Regulations of the,San'Joaquin,Local-,Health District.�' z,
<br /> ADDRESS/LOCATION ' 41
<br /> $Ida Mari..Sa Rd I.O NI. E 0 Dodds Pd. Jot.'
<br /> 'Ovn` ' Ed:7;ilpslt Pha a
<br /> er„s:.N
<br /> am' ' p
<br /> �'/�ddrese23!41'B.,Yerlposa Hoed " ' city
<br /> Coatractor's Name Ptirrianoe'Drillors License 240], Phon a
<br /> TYPB'OF WORK (Check): NEW°WELL /7. PEEPEN'/ RECONDITION /7::DESTRUCTION
<br /> PUMP INSTALLATION /�;. PuNp REPAIR /-]: PU1SP REPLACEIaNT 'I-T
<br /> DISTANCB TO NEAREST. SEPTIC TANK- SEWER LINES PIT PRIVY
<br /> r {� � " :SHGTAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE PIT `- OTHER': S� �!
<br /> INTENDED.'USETYPE OF WELL CONSTRUCTION.''SPECIFICATIONS,
<br /> Industrial r a ' $,_ Z Cable Tool.: Dia. of Well.Excavation.,..-
<br /> Damest�c/private r illed -D a..of .Well Casing
<br /> 3 + Domestic/p lic DrivenGauge of:Casing ;'•'. d4 ? , r. :ZTy Irr�gatia = Gravel Pack, Depth. of.:-Grout Seal
<br /> as other iy :
<br /> Rotaiy Type of='Grout
<br /> Other Other,Information •DseI •106
<br /> PUl� INSTALT,lMON: Contractor:
<br /> Type.of Pump H.P.,+ at t
<br /> REPLACBlQNT: �,f State Work Done •i F{
<br /> s
<br /> �0 it r PAIR ` L�, :State.Work'Done lot
<br /> r ` act•: :
<br /> EST&JCTION OF'WELL:}z Wall Diam--ter" APProximata.Depth
<br /> r.tDeacribe Material and Procedure ° �'�AL
<br /> ,
<br /> �j�hfs'1rYSC�F� r}r-�F�'�',ivrf ,; _.Y � 'r.' '. •. 1 r -'_ '''. '-. , � � - - r-i• a. cY:r+„u,, {
<br /> s}iireby igrae�.to�comply,;aith all:lays.sad regulations of the-Saa Joaquin;Local'Health-DistriCr"
<br /> r
<br /> tbe;StaCe�of`Califoraia:pextaining'to or;regulating well:coastiuction: Wittiini F1FTE8N jm 11
<br /> teYkcompletioa ofmy xork.on a;iaew well, I`will furnish the'Saa Jaaquin'.Local Health DistrictV11.2 �a
<br /> �iELI:`DRILLBRS REPORT of the,'wall 'aad notify .them before,putting the Well in use The above0
<br /> ht
<br /> nfora:etioa�is 'true to,the best of my knowledge and belief
<br /> rri-4r�.'f# '� y r v rrs w> k,, � ', .Y :�� �•
<br /> TITLE„_Part
<br /> SI af1Q80 ,
<br /> DRAW PLOT PLAN ON REVERSE SIDE ''» •:' { !
<br /> r �a FOR DEPARTMENT USE ONLY r : y`{
<br /> h - :x f 7ti r.r
<br /> ,APPLICATION,ACCEPTED,.BY DATE
<br /> �
<br /> � , ` :- :PHASE II-GROUT.'•INSPECTION P SE III FINAL INSPECTION I- t t�a+i
<br /> �iSPECTION BY - DATE INSPECTION BY 'DATE.
<br /> SCALLFORA GROUT'INSPECTION PRIOR•TO GROUTING AND FINAL INSP ION.
<br /> 4/72 IM
<br /> , ..-.``�,�t•F`'.��:r.X�tti,� '.y� r,�`y�'�}••R�,�r trai7�yi'� � le.. �.t uhet,.. :.�a.. .:k�+ e .,! [#:;:ek^".�=
<br />
|