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Page 4 of 51 <br /> ==z` IP)/ SAN JOAQUIN LDCAL�a TN DISTRICT C d M/d fie,rx-I <br /> 90fiOPFLCE USE: 1601 E. parelton'Ave., Stockton, Calif. /�/ 9 J �(y��' <br /> Z-1 <br /> TFOR WELL (109) TION O51 <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 76_}'7a lJ <br /> THIS PMLMIT EXPIRES I YEAR FROM DATE. ISSUED Date Issued 6 Z�L_0 <br /> (Complete in Triplicate) <br /> y Application is hereby made to the Sas Joaquin Wcol Health District fur a permit to construct <br /> and/or install the work herein described. This application in made in compliance with San Joequir <br /> County Ordinance`No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 90°� ./ IM l � Pd- , �+' CENSIvS TRACT <br /> JOB AnaREss cATIDN '�.. ° i�7�� � G <br /> }�yy ,r!�I-��� ® cuKr> <br /> j_Wner's Name .LUAH:{`9•�Q,i,;ry•rnsre ? n Phone <br /> -904962 <br /> Address d^>3D`%3 ll�!7. 99 �� J .CI. city <br /> Cop tractor's Naas License d caj& Phone .sem? <br /> „)sen 9 .per !.l j 'mss <br /> _ - <br /> TAPE-OP STORK (Cheek): NEu�NELG ! DEEPSN / ( RECONDITION DESTRUCTION <br /> PUMP INSTALLATION 1 f PUMP REPAIR 17 PUMP REPLACEMRMT 1 7 <br /> other <br /> III STANCE TO NEAREST: SEPTIC TANK MAS aEWER LINfiS PIT PRIVY <br /> 5ENAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRTy1TE DOMESTIC wELL — PUBLIC DOMESTIC HELL _ r <br /> INTS m USE TYPE OP HELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial _Cable Tool Dia, of Well Excavation ° <br /> :.Jl Domestic/private grilled Dia. of Well Casing " <br /> Domestic public _ Driven Gauge of Casing _429 <br /> 4 <br /> ,y Irrigation Gravel Pack Depth of Grout seal <br /> Cathodic Protection A., Rotary Type of Grout <br /> a 'Disposal _Other Oth'e'r Lnfor"tion 6„ <br /> �Geophysical - S ,face 5ea1 Lna�tailed By, r wl <br /> POMP INSTALLATION; Contractors/ C <br /> Type of.Pump M.P. M1IC`T <br /> PUMP REPLACEMENT: f/7 State' Nark Done �•' �e <br /> PUMP RfiPA$&: �I State 4%brk Dona - <br /> �.. _�__��,•�F��_.>--�,..-..c,. - .=.4.�..-��-- __ ___ ,-ApproximateDepth --_— __ <br /> DESTRUCTION OF WELL: Well Diameter A pp <br /> Describe Matar1u1 and-Praceduv4 <br /> �I }oreby agree to comply with all laws,sad regulariens of the San Joaquin Local Health Dietriot <br /> and the State of California partnini$g to ox r'eguTaEing well construction. Within FIFTEEN DAYS <br /> afAcr completion of my work on a new well. I will furnish the San Joaquin Local Health District a <br /> WLLL DRILLERS REPORT of the well and notify them-before putting the well In use. The above <br /> information is true to the beat of my knowledgs'and belief. I WILL CALL FOR A GROUT INSPECTION ,I <br /> PRIOR TOG :]TING AND A a AL <br /> INS <br /> 'CTI _ �d <br /> SIGNED T �d •-� <br /> RAW FAN ON RE SIDE <br /> 1 - R DEPARTMENT USE ONLY <br /> FEASE i <br /> _APPLICATION ACCEPTED BY GATE dj/L�Iw <br /> ADDixiONAL CDMtEEPTS: <br /> - P E-II GROUT-INSPECTLO - -- - P FLL NAt.YNSPE=ON� <br /> INSPECI'LON BYI . DATE �e INSPEpCTION BY DATE <br /> rites •,(/Ux S /Nus . �.« d�•rl��q � <br /> E N 426 Bev. l=Td it • - ��'Fa A o ���....+ <br /> A/2011 <br />