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�C: 30AQUIN LOCAL HEALTH DISTRICT <br /> 1601_ 1,, llazelton Ave. 0 Stockton, Calif, ' <br /> Telephone: (209) 466-6781 <br /> AP►l.TGATION FOR WELL CONSTRUCTION OR ruKp PERMIT Permit xo: <br /> THIS V ER.MIT EXPiRES I YEAR FROM BATS ISSM Date Issued�� 7= . <br /> (Complete In Triplicate) s1. <br /> -Ition is hereby made to the San Joaquin Local health District for A parmit to, "coeet24 t .tr <br /> install, the work herein described. This application is made in eooliance with%batt <br /> E Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loeai Iiaaltlt Din <br /> . Di RFSS/LOCATION b12l �' JA. Genas 1'RAC " <br /> G }= a All <br /> L S Name (T -- pylons J K <br /> } <br /> s gd r.l A. Cit] 't 0� <br /> —itractorla Naveog=&WZ2OV <br /> NO <br /> i <br /> E, OF WORK (Check)r NEW W ELL L-T Da�PL�M'/7 RR(�OND T14 M.�s.,D�?YO1� <br /> PULP INSTALLATIONE7 .Pam REPAIR PITl4P RVIACOWNr Y <br /> Other L.iSTANCE TO NEAREST: SEPTIC TANK . SBNER LINES PH <br /> SEWAGE D7.SPOSAL FIELD ' CSS gACE PIT 1 <br /> 0 L/ h <br /> PROP INS - PRM=- P <br /> �INTENDED USE 1'YPS OF WELLCONSTRWrION. Q18 <br /> 'lndms trial Cable Tool Dia."of .Yell>zZeavatiop ,,w� <br /> Domestic/private Drilled Dia p6tft .l- Caste*``" <br /> Domestic/public Driven Gaffs Of .Casietg'=' -� <br /> �. Irrigation Gravel Pack Depth af,l�at ,,. <br /> - y <br /> Cathodic Protection , Rotary Sypa of'Gront " .: <br /> Disposal Other Other Wag " tioa <br /> Ceophyeical 5 �� eitl. <br /> PUMP INSTALL.ATIONj Contracto x <br /> Type of Pump " <br /> PUMP REPLACEIfMi L—T State Work Done i <br /> � 4 <br /> ���p A <br /> PERP :REPAIR: � State Work Done r« tat . <br /> ' <br /> ESTRUCTION OF WELL: Well Diameter Approximts Depth <br /> Describe Material and Procedure , <br /> I hereby agree to comply with all laws god N t ons of M M 3o&q;MDist Ct <br /> and the State of California pertaining to or regulating wolfconstruction. W1 In. P*Tf- DAYS <br /> after completion of my work on a new well. I will furnish the San Joaquin Loral Health Distriet..a <br /> WE.U. DRILLERS REPORT of the well and notify thso before putting the well In use. The above <br /> Information is true to the best of my knovledpbelief. 1 BILL CALL 4OR A CPXW INSPECT <br /> PhiOR O G UTINC AND A FINAL, INSPECTI 1Q � <br /> 51C;t�1 D / <br /> D E SID <br /> FOR DEPARtl1RW USE (OLT <br /> t'ATION ACCEPTED 8Y _ DATE ; <br /> `ani;1710NAL COMMENTS, _ <br /> PEi n It GROUT INSPECTION PW18 III/FDULILISPSCTrOiI <br /> DATE INSPECrIOM V - ND= 9-a <br /> i.!, r, R„v. 1-74 1-74 ZK <br /> z <br />