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s <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _- 1601 E. Hazelton Ave.. Stockton, Calif. <br /> - _-I Telephone: (209) 466-67$1 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perdt NOr`7 «' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSURD Datetxaeti �r <br /> (Complete In Triplicate) " <br /> is herebv made to the San .Joaquin Local Health District for 9' paraiit t6. iaaticuikct <br /> �CaLl the work herein described. This application to made in complieec6 Vith:46nt' <br /> --'i.rance. No. 1862 and the Rules and Regulations of the San Joaquin Local Health DisttT CC: <br /> !,M'SS/LOCATION .s <br /> t <br />.. P / - .- <br /> ?vame e rt �6i �a,11� re-1 A <br /> City <br /> : actor's Name L1Cense;l;. ORep' CLC ? ►. <br /> OF' WORK (Check): NEW WELT. L7 DEEPEN /T CORD ON f DBSTR�ft T y +� <br /> PUMP INSTALLATION / PN11� RBPAIR� NRBPLAT � `T , "F <br /> Other L7 <br /> rk <br /> .'.+.^rCE TO NEAREST: SEPTIC TANK ._... SN3WNTR LIMBS PIT PRIVY <br /> ...._..� <br /> SEWAGE DISPOSAL FIELD GBSSFOOL/SEEPy1G8;'PIT�+ _7 :OTHRR`' � <br /> PROPERTY LINK - PRIVATE:DONE§TIC " `—`, <br /> TF.NDED [TSNI TYPE OF WELLt# #¢. ON SPILCINtICATI01�8 :- ' <br /> -Industrial Cable Tool Al of1iieWNttcanat1oa 'I= <br /> Domestic/private Drilled <br /> Domestic/public Driven <br />._Y lrrigation Gravel Pack-- <br /> Cathodic <br /> ack:Cathodic Protection Rotary FTy of GTrout,: r <br /> Disposal Other _ ,iOthiarL, lfoti>it <br />--Geophysical ; ..pr ,He}a1�I>als3ied - <br /> '.Yr�n u.�riYrl.' <br /> Z1t INSTALLATION: Contractor P <br /> Type of Pump - .P.. 4L-u,' <br />[IMP REPLACEMENT: L7 State Work Done <br /> r �s !, <br /> UMP REPAIR: �7 <br /> State Work Done R. <br /> =r� <br />'S-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 1 `k <br /> 3 <br /> hereby agree to comply with all lava and reju'lations of the Saw.JoaqUIU <br /> HO&Ith Diattr ct. <br /> lid rhe State of California pertaining to or regulating x81? ro"truttian. Within PIFTBINN DAYS <br /> f L e r completion of my work on a new well, I will furnish the.$an.Joaqula L"Al "Calth" Diettefev- <br /> F1.1. I]RILLERS REPORT of the well and notify then before petti#s-thf.rgii fn uq&.'' .The abave k <br /> nformntion is true to the best of my kn 1 Nei. ,:.I ii#LL CALL PORA':G�DtNt. xtiSNs8CTI0 <br />`tUEt '.f0 GROU t; AND A FINAL INSPE ; `Y <br /> DRAW ' 011 . ID i <br /> EPARTir M USE ONLY <br /> ° :k <br /> ACCEPTED BY �4 DATB.�-46 7, <br />' i-,t)tdAL COMMENTS. r' <br /> PHASE Ij GROUT INSPECTION Puns III !►INAL IN18PlNiRI0N # <br /> !'1C1T: By 1 DATE INSPeaXON NY do VXM <br /> f, ,.,•.x. 1-74 N 77 '.' F . <br />