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<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR OFFIC?
<br /> USE: 1601 E. Hazelton'Ave. ' Stockton, Calif.
<br /> ,c Telephone.%.'(209)`466=6781;.
<br /> PLICATION FOR WELL CONSTRUCTIONAOR MT PERMIT Permit No _7z;id_ L'
<br /> THIS PERMIT EXPIRES .1'YEAR FROM DATE'-ISSUED ; DaEe Ieauedt 2/'-
<br /> " (Complete Ia'Triplicate)
<br /> llpplication`iis :hereby de, C the,San4oaquin.Local, Health'Die trict for 1a permit ttCa,c+ait C ct
<br /> tend/or,.instIl;ttie �ror here n descxibec?. This.app�icgtion is'made':is'�coatplia�ce' rtthSAIi��Tui�►
<br /> County;OrdinaiiNb i�1862.and,the-,Rules,'and:-Regulations 1.00"the San71oaqui>S Locral e`dI+ ist c .
<br /> �°"�'�t ': s ;�'.r�tfi�l.S���`".sr�t;3ns �+ � :�; . .• f .r,��r,ra: ,:,t•t�r!:r Gt7 '1.": �,>s<Y i^��,f,,s',� ,r -,' � �
<br /> JOB
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<br /> t1740 t 4 9 ' J�f' r'!Owaer.'s NfltB ,
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<br /> Address n�`sem o. aJ Z. ,
<br /> Cozitxactor!aNama . Liceitae 1, Phone"
<br /> E 0" WORKu(Cherlc) NEW WELL°/7 DEEPEN=/7 RECONDITION f f DESTRUCTION ,
<br /> :INSTALLATION'. PUMP REPAIR L�f PUMP REPLACI N'r t ry
<br /> th 177 '
<br /> DISTANCE TO.NEAREST,ASEPTIC.TANK SEWER,LINES.-.:. . -•PIT PRIVY , ky . .
<br /> . SEWAGE DISPOSAL FIELD CESSPOOLf SEEPAGE PIT !OTM
<br /> INTENDED AUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br /> 7sidtast7Cia3 �n1 y > :Cable Tool Dia. ofWe1 EYcavation; � ^�
<br /> e : � - Drilled Dia of .V411 Cassa `° �'�,> :•zr s•
<br /> e ,DotaestC/Private g
<br /> bdaresti /pud ic" Drfvea Gau'ge'of'C,asiag.��V ;f
<br /> galioit �, � , � Gravel Pack ;Depth-6f'-Grout
<br /> Other `" ^1� "et.� Rotary Type of Grout :, --
<br /> °�_. s + Y . 0ther _OtheInfo
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<br /> ....4 a'"TF ,a:: " - s ; M s t ;c°.s._.}'S, .•�f", ff�P ..
<br /> ON i: rCQatxBctor �&Y
<br /> "., w�,�Type'�!'Of.Pu �. �...,�,, �, «yam a.;a., .t.B.P.' '•��'
<br /> FUMPF LACEHENT sD., ate AWork Done
<br /> REPAIR: �+� State Work Dane # �-' '
<br /> CTION �r}.+OF.� =-.�w ter . Approscimat
<br /> •'� s�,-.c.ww.+s. �•- C A r,.'•�"�1��� '
<br /> pESTRU ,We11�Diaiie3 . a e�DaPth
<br /> „x Describe Material and Procedure �
<br /> heireby;agree to aomplyiwith'411,Laws and regulations of,.the San-,Joaquin Local MealthlDistric
<br /> uad tYie'sua of `California pertaining to?or�regulatiug wellrconstruction Within'%FIFTgEN l71�Y
<br /> afte co pYe°t l;o yxw k oai a ries vell> I'iaill furnish"the San:Joaquin Local Health Diatric
<br /> T�'P.?L DRILLffitS�R8P0 afiof =B*well,aud,notify=them,before puttingthe.well9in;UseJ�Tii45",wve
<br /> iaf�1 ,t' 'g i�:+�aqs'-�".".6.�` A-.•,y� •! "";of my kn-owledge and belief
<br /> GED
<br /> W PLOT P ON EMMZ SIDE
<br /> 45a rte y ^ FOR,DEPARTMMIT USE ONLY t� t-
<br /> 7.
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<br /> •APPLICATION.ACCEPTED BY !� iL .'
<br /> ?ADnITIONAL COI�LNT5
<br /> hia PHASE II GROUT INSPECTION. ~`r PHASE IIII FINAL INSPL+l;FION,<w }
<br /> Y F r
<br /> INSPECTION,BY" DATE INSPE 0X BY DA'' -3 r
<br /> ,-
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<br /> CALL FOR-Y GROUT INSPECTION,.PRIOR,TO GROUTING AND 1?I.NALwINS]ECTI0N. ; _ „•,; .,....W..w __,..._..�.�.4 �.
<br /> 3 H.1426 : x 4/72 1M
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