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<br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT • " >Q
<br /> FOR OFFICE 'USE:
<br /> 1601 E. Hazelton Ave.. Stockton, Calif. -
<br /> Telephone: {204) 466.6751
<br /> APPLICATION FOR. WELL CONSTRUCTION y')R PUMP PERMIT Permit No.:7Z
<br /> • THIS PERMIT EVIRES 1 YEAR FROM DATE,ISSUED ' ;':Data 18sued.1Y _
<br /> z C (Complete In Triplicate)
<br /> •Applicaticn.x:is-he'reb :'made-to the San Joaquin- Local Health District-for'evpermitItto?const t
<br /> axed/ar insiell thz'.work herein described. This application•ismade' in,cozp1Liira'vttMSin'VJelaqu ,
<br /> County'.Ordinaace No
<br /> 1862:4ndi the Rules and Regulations of-the-San JoaquinjLocal4H"'-It�htlDisttict
<br /> JOB`,ADDRESS%LOCATION ~I e30 a s' CENSUS TS/I,T ..
<br /> Okr.
<br /> Ph"aIf RfA.QTY w.rraer'a Hamate � ..rl4v«1-+� - �-R`:7
<br /> dress` p` D " City,
<br /> Lontrsctor'�a,Name �l.Rii+ License # '' Ph6naiar 'll
<br /> 'OF a O tChecic)s °NEW y WELL'I„�T" DEEPEN'/7 RECONDITION /7, DESTR3JC7'ION
<br /> INSTALLATIO -] P pump 'RSPI.ACSl3ENT�+//��/
<br /> Other.�L
<br /> DISTAt�'CE TO:NEAREST vt SEPTIC,TANK, :r. SEWER,LINES; .. . ', PIT.'PRCVYE.:� ;
<br /> " , EiiAGE SDISPOSAL'FIELD CESSPOOi/sEEPAGB $P$IT; OTHE�L _ �
<br /> � ��,
<br /> fINTgNDED USE T TYPE OF•-WELL _ r :~ CONSTRUCTION:,SPECIFICATIONS'
<br /> Indiistrial + , ra �
<br /> Cable:.Too1 Dia.wof:.WellaBxcavatiou +
<br /> Daeaticfprivate
<br /> Drilled Dia. of;well;Casing >�,��xr
<br /> `Domeetic�public ��' Driven . Gauge of; Casing �-1!i" k -'�
<br /> +� xiiigationi. Gravel Pack Depth"`ofs;Grout Seal.• � ;r,.
<br /> ;p.$ Latherw{'°Fa c2 Rotary
<br /> of'Grout �'
<br /> Other Ot ei Infcsrmatian _ ._ :w -.. c -�
<br /> ".rw'�a+ #wia:�:.•�r.�.. "i-Y2d£ � - s.. fr,:s�'. „a' 6 3're,L+7;i;�.
<br /> M�i,:;w:�'�P'S:, :Vv.at :.•-l:.„3- g' Y i�`C.SY' ..i." ;.w .`Fr.
<br /> P[Y1� IN5TAI.X.ATIOl�if€ ,'` Contractor 'r r , J
<br /> !:;�-Er 'r r�,yy4i�" r i,f.,.T�•s �f'+�" ^�1 � �W7 rt:. „e.� ti•>!rrFd."�Pk:'.�S;�g�P.'�, t'!
<br /> P,IDlP R�PLACEMBNT•'`OL`3A L/�State work DanVIP
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<br /> RSPAIRI $tatC work DoneWA
<br /> work
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<br /> ���,y�.#>'G
<br /> PE5TRUC1"I8S?i'OF wBLLs we11;.DiamPter Appro�.mat Dep
<br /> th
<br /> gDescribe Material and Procedure z" p"a7
<br /> I�hereb ,i
<br /> le. t comply,.with,•all-laws,.and re ions of,the.San.Joaquin Local HealthtDistr3ct�
<br /> Y g t
<br /> `'and;tIie, State,of Califs-ria pertaining ;to or"regulating well, construction. wir to"FIF DAXS
<br /> a Eter tromp]etiLon of goy W:rSc on anew well, 'I will furnish'the Saa','Joag lin Local;tdealth�Dist=ict
<br /> fl1M PRILLERS SORT of'the well and notify 'them before putting the wall iarusa r The abava
<br /> "*Ninforc�ation 'ia true to the berg r of kyr.knowledge and belief.'
<br /> S U _
<br /> ^ ;. •: v.. �:•a DRAW PLOT PLAN .ON R RWE
<br /> « +•sa , ,ry. FOR DEPARTMENT USE ONLY
<br /> ABASE Is'. 1 + , In
<br /> APPLICATION ACCEPZ_:_ D BY ` iL�✓-�' _ SATE -S
<br /> '•ADDITION!►L COM�NT./ '' .;w.. _ r. ,:. .� ... �����
<br /> PWV II GRM". INSPECTION PHASE III I+INAL INSPECTION•r �� .
<br /> .. .
<br /> `INSPECTION ESC DATE . INSPECTION •.SY . DATE ..�
<br /> x " CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ,. a
<br /> _ 4172 ;IM
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