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r 'S <br /> SAN JOAQUIN LOCAL HB.'+I.TH DISTRICT . <br /> FaS OFFICE USE, .'1601, E, Haaelton Ave., Stockton. Calif. � <br /> Telephone: (204) 466-6761 <br /> ArrLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit no•rI°-. ' <br /> THIS PERMIT EXPIRES 1 YEAR PROH DATE ISSUED Data Isavad L-iZ-rac9 <br /> (Complete In Triplicate) <br /> Application is hereby made to the SEn Joaquin Local Health District for permit to eonctroct <br /> and/or ine�tall the work herein described. This pplica ion is made in compliance with SM J. <br /> Cour:ty Ordinance No. 1$ of the San Joaquin Local Health Dia ct.l .1 <br /> CENSUS TRACT f `x <br /> JOB ADDRESS/LOCATI " ...... ''f <br /> Onmar t e Name - - <br /> Phoned <br /> Address <br /> - - r City- <br /> Contractora Rama License �fG. ,? oce� <br /> NEW WELL /� DEEPEN' 7 RECONDITION %7 DrSTRUCTION <br /> TYPE OF WORK (Check): °Iq <br /> �• <br /> PUMP INSTALLATION &Pump REPAIR L� PTSD REPLACMUNT <br /> Other L7 �. <br /> Y FISTARCE TO-wwXST: SEPTIC TANK �,� ES <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CSPOOL/SEEPAGE PIT OTM ....._ <br /> PMPERTY LINE - PRIVMM MMSnC P t`$ <br /> INTENDED USE TYPE OF WELL :OFSPECIFICATIONS ^:;* <br /> Cable Tool Dia. of Will Excavation <br /> Domestic/private Drilled Dia. .of Well Casing <br /> .._...... Domestic/public. + Drives Gauge of Calling <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection „�_ Rotary Typo of Grout <br /> ..�_ Other Other .Inforaation <br /> Disposal S f e s B <br /> Ceophyaioal ., - <br /> pUjjP IpgTAW ATlpli: Contractor 'cr''s'"' <br /> H.P. <br /> Type of Pump <br /> . MP ROPLAC8[ iT= State Work Done i' w <br /> s L ,. <br /> PUMP:RBPAISt Scala Work Dana <br /> E Approximate Depth <br />'jSTRUCTION OF WELL= Weli Diagster r' <br /> } Describe Material and Procedure �. <br /> art <br /> etr ct <br /> e to c 1 with all lana and rag tions o t e San Joaq a Within FIPT� Do$ <br /> I hereby omP y ti well conatructiop. <br /> ,sad theStatsof California pertaining to or regale . ug Local Health Distriot a , <br /> cork on'a now well$ I will furnish the San Joaquin The atia�w� <br /> after•cotipLetion of m4►:: airing the. ira11 is uas. <br /> . WELL DMUM„gMPORT of the 'well:,and notify 1than before p <br /> . infar+eation''Iis true'-to the•beat;of L asq.knowiedga and belies. .I WILL CALL TOR A <br /> A FI AL INSPl�CTION.. <br /> PRIOR.TO ioRA �, TITLE <br /> SIGNID RSS SID <br /> DRAW LAN og <br /> DBPARTlO�? USE ONLY , <br /> PHASE''I' <br /> APPLICATION ACCEPTED BY <br /> i. ADDITIONAL COM EM: PRASE <br /> I PSCTION <br /> S c P8 r y <br /> INSPECTION <br /> INSPECTI s $Y,. DATB F, <br /> l•d ib' {}� � � � `F <br /> $, 11 1426' Rev 144 <br /> r �. E + " 1^•:` �-:i� xt +M.• =i>.,. r k.. y..' { ; '( •, R^.- :+ e <br /> k'�� •,A y � I'".'«°k �,,,�-.� Tt�.:s.�+,�,,i e -"x. .�,li:.Mi . . rsz. .m. 3 . <br />