|
i r
<br /> F�P
<br /> 3 r.�7./.y _ 1
<br /> ' s 30AQUIN LOCAL HEALTH DISTRICT 'F `
<br /> a w .,
<br /> SAN '
<br /> FOE OFFICE USE:- 1'0I E ..Ha%eiton Ave., Sto6k.-on, Calif.
<br /> (2093 '4664781 ,zr
<br /> F: a APPLICATION FOR+WELL CONSTRUCTION QFt PUMP PEI{MIT ' ` Permit Ha i = �.+ '
<br /> ` THIS PERMIT EXPIRE5 1:YEAR,FROW DATE ISSUED :,Date Ias
<br /> (Complete In Triplicate) max'") s � " 3
<br /> {ApgliaaCion` s hereby made to the San Joaquin Locale Health Diatrictxfoar�aermtta €
<br /> a and/or install the;wmrkherein''descrlbed :This agplYcation #s mallei +ampaa�e' ognin.
<br /> Countq'Ordinance No 1$62 and the Rules and Regulations of the h an . oaqu ac �t.4
<br /> P "'i! f �` r r_ s r n. T ° "`" _" '-'r }"x r� 3 ^•- y''i* "`a.sk, ? rh¢ '7 _F .r"'' .
<br /> r �.r �.e' _ 3 _ M�� 'ix -„'+xrd J�7..3.2`' a�"'',-F� -.tr•.I
<br /> 'JOB ADDRESS/LOGATION 3 y 4 ?C SLiSx k
<br /> Address
<br /> Contxactor's NameZzajr
<br /> License 4 s.
<br /> w �J
<br /> �; STYPE OF'"WORK:(ChL& NEkV WELL 41 „DEEM] f-7 '"REGUNDITION��4DESTEU�'I01�� � ��u?t �� �'r` -1
<br /> y A
<br /> 'PUMP IHSTALLATxON / PUMP REPAIR
<br /> v Other " .war
<br /> �' � '.iv{5j.'f s `^� ..t•..rA. . '--1 ^a �` i rti r o'�' r�=r>� �.3f
<br /> �,'DISTANCE TO NEAREST• SEPTIC TANK y aEWM. LWES;.
<br /> y- t SEWAGE AISPOSAI�°*FIELUD .C� SPOOL/,SEEPAGE"PITT .C ,
<br /> x# " PROPERTY"LINE PRIVATE DOMESTIC PVJb ICgnows ICxWE _
<br /> t a � INTENDED OUSE z TYPE OE WELL 4 .CONSTRUCTION=SP�GIQDL =
<br /> K
<br /> Ia trial a CablezTool* Df s of WeZZ Excsir t1dir,
<br /> . omestidjorivate r Dx llad Dia, of Well Casing Vis'1 - �`
<br /> �Domesle public I�r ear Gauge of Casin � �
<br /> A Ixxigationv ` { h r r-Pack , Depth QfGr'out
<br /> ti Gathodi c Protection Rotary Y Type of'Grote
<br /> 4ti y t tit OtLtExrnfOrID8t0A"a`�tw' h R�IMADe
<br /> Disposal O
<br /> # �, Ceoph F-_ r � a cry Surface Seal I istall -
<br /> - � e,.f '`] trvz� �u t to ,t.._ ��''?;: n r 6 i.. r � ��*, _''1•E fh�fi. - �ya � L1�� mom+. ,� �;i��v �, fi a
<br /> e � lO' iN$TA3 CATION t Contractor r a R { x
<br /> _ d 6 v C” s Type'Qf2-Pltmp -fwd ' s' ?°`>>. i'. •.-�. •:�- r �• -
<br /> +awe ,`.' '• IN
<br /> -Pt
<br /> a e P[7HP REPAIR r ti h J State WorkxDone f r X3 , T;:Ba *°
<br /> �• a.•k wa s-� ) u 2 .r ,? i"� rF"--,-.1 p' f- }.�:.y i3 ,T–'� a, '3i. c —,A_
<br /> •t S" }) .. -Y........ l�, • Y "Y r,�
<br /> DES TRUCxION OR WELL r Describe Matterial,rand Procedures pr ) y
<br /> a l t
<br /> < y +
<br /> r�Y
<br /> vv
<br /> '. I�erebyagree toy comply,wJth all lads and regulations ;of the Sans3oaquf LocalHe# r{
<br /> L' ¢ and Che«States ofCalifornia pertaining to orC regating'wellcot�sr+tt:foidi�ff� s�
<br /> fter completion of<my raoilc on a neer raellT=
<br /> �IaI mill st�rnish;the 5att oa a
<br /> WEE3: D LLERS =REPORT of the well sad notify them beforesputtfagtheive ` a
<br /> { m '_ a' T k !r•%!TS)4•Si' < %-
<br /> ,3rforma• s�truerta,the beat. vledge and ef b'I} WII,ICATLFOR*A :G�U�
<br /> P.HIOR •TO:
<br /> UTI:IG ANDA FIN
<br /> K I
<br /> _ o iR{k. .,tl �.> �✓ - '., : .PLAN.ON? SRSESIDB ' sic %- ' ` _ t .� �_".�1•
<br /> AVY b tr
<br /> y r s, a y rc POFL DEPARTXM O$Ir V►�+.i .+M r r
<br /> x PHASE
<br /> 3 APPLICATION ACCEPTSi3 BY `� _ DATE- / .
<br /> • A�DITION�►L CO
<br /> +w k ' P�' INALINSPECTI
<br /> 0i I GRQOT-r.:INSPECTION xx S III'F t k r
<br /> I1d5PECTION BY DATE Ia INSPECTION.'_$Y `�DATE=:' - ...
<br /> 426 f .r e�Ar
<br /> r-
<br /> �� :,� ��-F ,uri.h�tk 3r„sur� g'"A rri �"^*.`�Y 3'Xtt-��� rEb',� � .�t `ar`�t���wd:n � -4. ��' '� zk �+-x'�1' � di,'R`•
<br /> W' �{ ,;yq 3Z X,...b-- b- T 1 � \ I.M r Lk 5 �iy,` 8 EJs' `•[h.' _4,...6. �4.'�., eek •i.-
<br /> f e �� _ _ �,.•r � �� -4...k x r.._G rKc.,- � r Y,:~ k { '�"L � 'r-"'1,. S >,``"�, r� yam✓+': t,_< .x.
<br />
|