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S �fri FIL °A <br /> ..�� •,www w ,s"i .'«: <br /> 14 IV_ <br /> ° SAN JOAQUIN LOCAL. HEALTH DISTRICT /1��� �.kJ'r." <br /> " QItiAFICL� USE. <br /> 1601 E. Hazelton Ave., Stockton, Catii. <br /> Tclephon.,: (209) 466-6711 r. <br /> < 'xrr APPLICATION: FOR WELL CONSTRUCTION OR PUMP PERMIT Permit tkr: �/ z ; <br /> �: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE !SSTJED Date Iesued/ � �� <br /> �., (Complete In'Triplicate) �- a <br /> App2, cation Ss .tr'retiy made to the :San Joaquin Local Health District for. a pe:cmit! to cons Uct); <br /> �4= r inatal l;`the work herain',.described. This application is made in compliance-,with San­Jaaquin <br /> f�su�%Cy�Ordix�an^e°Nn::)8fi2 and the Rul and-Re ulations of :he Sari Joaq:iin Local Health Disrri <br /> �! Z � J <br /> :� AUDRE55/ZCLATION — CENSUS TRACT *' ,� e .. j A <br /> T' E k t <br /> t 1W` SSS <br /> d OWlter-s`Na1de F <br /> � `` 'r 2•Rr.�..0 � .Phone <br /> dxe8s�*; - N,` Cit, <br /> %an Joaquin F=p o. <br /> h <br /> CgtltrictorsS�'Name (Division of San haqu:m Sulpaur ca; License �j�Q � phonB <br /> all <br /> y t <br /> .PE..O�F+WORK fit(.,eck) i` NEW.WELL .CT DEEPEN'/7 RECONDITION / I .DESTRUCTION <br /> >` Ps�MP INSTALLATION / UMP REPAIR. /% PUMP ,REPLACEMLNT: tr����H�* <br /> x�x Ocher FL/. .? <br /> . DISTI►NC$ TO"NEAiL.JT ,SEPT1C,aTANx SEWER LINES PIT PRIVY <br /> ',SEWAGE B�SPOSAL FIELD"r"° CESSi'OOL/SEEPACE PIT:l UT�1;R <br /> } `'{P'tOPEPiiX TwE =PRTVATF, DOKESiIC WFLL PLBLT.C'7UMESTIC 1•:_r.T, <br /> INTENDEDx JSE T3t�'F OF WELL CONSTRUCTION SPf IFICATLUlia" <br /> dutrsl ` f s � _ -Cable Tool Dia.' of Well.-.Excav_:-•ion' _ ' } ' <br /> Rotaeatic%pried+k;' Drilled Lia. of Well Casing <br /> AOW18tic/public .k �, 'w� Driven Gauge of .Casing' 14 ; <br /> j <br /> Crs�ve.� Pack .Depth of Grout.:Seal K <br /> p'+Fl!"' Gtltl+od+c PrOCOctiUn 5 Rotary Type of .Grout <br /> + 0.>tD �posa� Other . Other Information ;> , rr t <br /> Surface Seal _instaited'BY. <br /> ,PPUMP YNSTA�:..gTION Contractor �.�.1j �Z.a �c r .J <br /> Type .:of Pump _ � at.c� � H P <br /> P[T P .1tLPLACEFu�NT L/ tace Work Done <br /> -REPAIR.,i` r' / State Work Done c „ <br /> SES_ UC'£TONisgf' <br /> WE, <br /> E L' We11tFDismeter Approximate Depth <br /> .' `'`�'�����rw'� �•' :.Describe Material ar.La ftccedu're - �xs �.'• <br /> 3 eleuy 4agra a Coycomply �►1th all laws'and regulations of: the San-Joaquin Local Healti..District f <br /> 'tlte State;of Csliforala5,pertaining to or regulating well'construction Within'FIETEEN:DAYS+ a y <br /> gf ompletiom of :my work<on a new well, I will furnish" the San Joaquin Local Health Distrizty'al <br /> WEYI �}RILS.Ec�«S REPORT..":of Che'well a;nd norisy them before putting the: well in use. . The above <br /> well �;'.. a_ <br /> orwat Fa i.strue to'tlie;best of »y knowledge and bell f. I WILL Q,4II.,FOR GROUT INSPECTION :. <br /> IOr'tTO CnGUTP3C AND It FINAL`INSPECTION. <br /> (Division of Sam Jaaquirt Scup{ar CO.) t <br /> .S;EGNED - 1 TITLE <br /> uyh"' •` s� PLOT'PLAN �]N REVERSE SIDE - a�tcr, o r <br /> FOR DFPARTME\*T USE ONLY . <br /> xPtIASE Ji , <br /> APPLICATIONACCEPTED BY { ✓ DATEZ <br /> AADITIQO COMMENTS '— <br /> '"r PHASE I'l GROUT INSPECTION PHASE III/FINAL INSPECTIO $* <br /> NSPECTION By; DATE INSPEC`r.'ION SY <br /> E <br /> Rev <br /> HR1426 1-74 7fa'J� /YO��•�,� /, b!�] F( <br /> y(?i '�M�"'�j`�si'^"'ilC� 4�+�«• rve.:v- r-= t F,� 7�. i 1.,.ti�+�hw-i yr=w.e s a erri. r 'rrWl+� �Rr'9L�� -, ?W <br /> <, '"?. 3. x k _1 ni•,, z y�4�S� ,rapµ. <br />