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�:-.ter~ T 1 ; { ,•,x -.lam f1 '�'` - - - t ;_ ',r a T .ar -`e <br /> 44, <br /> 1 <br /> SX4 JOAQUIN WCAL.)1 ALTZI ,DISTRICT <br /> FOR OFFICE USE, j/ 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephones (209) 466-5781 <br /> .` PPLICATION FOR WELL CONSTRUCTION OR PUIIP PMWT <br /> Permit No. <br /> t THIS PERMIT EXPIRES I YEAR FROWDAT'3 ISSUED� Date Issaed� $./7 <br /> . (Complete In Triplicate) F <br /> Application'-is hereby aaade to the San Joaquin Waal Health District for-a permit'to coitstract�ti� n <br /> aad/or install the Work fiersin described. This application is made'in'compliance with"l' Joaq . <br /> X6unty Ordimmes'No., 1862 and the Rules and IsSulations of t`na San Joaquin Lotal'1.�altli}Dfstri� <br /> �a p, <br /> ADDRESS/LOCATION CENSUSoTRACTr <br /> 10 <br /> w .. <br /> .Phc+na ��•,��',[.(���.. <br /> �}r:as - Aa City •f av 1. <br /> tractor's Now _,.,1 ..c.e.. .. �.,....:., -- License /JAS Phone <br /> ` rrrawr e <br /> Ol► �}OR�( (Check)2 NEW 1;ELL LW ]A'um QRECONDITION R �DESTRUCTION "� - <br /> imp INSTALLATION L-7 PUMP 'RKPAIR'/- PI]MP!-REPLAcmdmT <br /> Other <br /> a <br /> STANCE TO NST: SEF-110 TANK SEWER LINES PIx PRIVY, <br /> SEtion"l!)spdm F. FIBI.1) CESSPOOL/SELFAGb,-PIT <br /> DEA USE TYPE OF WELL, COHSTRUCTI91SPECIFICATIOI�FS <br /> ' I�tdeastria�� Cable Tool Dia. .of Well.Excavation" <br /> fiQsnesti/privNta Drilled Dia. of Well Cs sing ._ <br /> �II�tMFe�tiClFuh]i ' Drinan, Gauge of Casing <br /> garcon Gravel:Pack Depth of Grout Seal <br /> 1}ti)111ir Rotary Type of Grout a• <br /> Other Other Information- <br /> SxLATI4Nt Contractor •' si .. ., <br /> Type of Pusq+ H.P. x: s <br /> {{{ <br /> 31EPF.AC6lO±tiT• State Work Done k' ,r <br /> PD @'REPAIRt State Work Dene <br /> OCTTON 0? V=t Well Dia&wter ' � AppzaximateirDapth '- ,�-� ,: <br /> Describe Material and Procedure ry <br /> 4�, <br /> f TMb area :to compRy with all laws and regulations of the San Joaquin Local. Bealth',Dlstrictt `k " <br /> ' i�t1t 8t�4Ca of.California pertaining to or regulating well construction., Within FIFPB�Y1A1'$� <br /> sf'C�Ix coiNp :otion of my work on it"naw welt, I will furnish,the 5atiJoaquin;Local' $ealth;Diercta <br /> CLL:2 LLE1&;.ifVORT. of, the wall and aotifq them befoxe putting" wlte Snell in use; .' The a8a <br /> Atb atiion,'iM true to :the beat of my'kaowledge and belief � <br /> TITLE <br /> DRAW PIAT PLAP-.ON yREMSE 5II�B <br /> �c FOR_ DEPARTHM USE:ONLY <br /> TZbh ACCEPTED'SYDAM <br /> 194 aia <br /> ,_ 7 <br /> �A>�Il'Z�IAI+ COt�l4T8 s. .: <br /> YI GROU"I INSPECTION PHASE`•III INAL IHSPE.TION 1k w ` <br /> 'i3 �L'CTION FY DATE INSPECTION BY 1 - DATE <br /> %_ FOR A.CROS.'I14$PECTI0�1, PRIOR T0,GROUTING ADHD -FINAL INSPE4"1'IO�i. <br />