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+pQ`zr =fit <br /> y j <br /> j <br /> �/ , <br /> 5A'1 JOAQUIN LOCAL i1EALTH DISTRICT k' <br /> a=_ O1 FILE USs: 1601 E. Hazelton Ave., <br /> , Stockton, Calif. <br /> Toiephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUKj' Pi:R."SIT Pcrmit No. �.SGt3ltJ <br /> 6,5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ! <br /> t <br /> (Complete In Triplicate) a <br /> ,%pplicarion is hereby made to the San Joaquin Local lie altiti District for permit to ch'Struct <br /> and/or .install thr.;,+pork herein described. ' This application is he SadeJoa uincompLocalek[ealithSD'ixtrict�n � � ,• <br /> County Ordinance too. 1862 and the Rules and Regulations of t q . -' <br /> CENSUS TRACT k v- q;+ <br /> JOB ADDRESS/LOCATION I I <br /> F Phone t' . I <br /> Owner's, Name R { <br /> Cit} <br /> Address° 0 /t <br /> License `7Phon , <br /> Contractor's Nauta / J/ <br /> F ,: J DEEPEN / / RECONDITION / / DESTRUCTION �T <br /> TYPE OF„WORK (Check): NL'LJ WELL /�� _ ' <br /> p ,iP REPLACEMENT <br /> PUMP INS'iALLL1TI0ti Ill POMP REPAIR / I <br /> otber <br /> PIT PRIVY <br /> DISTA�Ca TO NEAREST: SEPTIC TANK SEI ER LINES OTHER <br /> SEWAGE llISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> -------------- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SP`:CIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation \� f <br /> Drilled Dia. of. Well Casing <br /> Domestic/private al <br /> ' o _. Driven Gauge of Casing <br /> �Jomcstic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ..,Other Rotary Type of Grout <br /> Other Other Information _ <br /> 4` <br /> i Ui jq' INSTALLATION: Contractor <br /> Tyre of Pump <br /> x N q <br /> : <br /> State Work Done'U`'!P nEPLACE};1>NT: I / <br /> 1 <br /> i il,iP 't.EPAIR: / _/ State Work Done --- <br /> Approximate Depth <br /> DFNTRUC?I0N OF WrLL: Well Diameter <br /> Describe leiate,'xal and Procedure : j <br /> ict <br /> I hereby,'aP,ree to CO-,ply wit? all Jaws and reyul.ationS of rile San Joaquin Local Health DistDAYS <br /> and thn State of Crliforn4a pertaining to or regulatiag <br /> furnisisethell cSan tJoaquin.Local hHealth Din istrict a _ �•; <br /> .,iter;<completiva of my worn on a new well, I will <br /> WILL DRILLI'sliS REPORT of the Weil and notify them before putting the well in use. The above <br /> infore:aticn is true to the best of my knowledge and belief. ,.d,., <br /> J <br /> v` TITLEIC�L as <br /> sic, _j -' �' (DRAid PLOT PL9� Oti i<F.Vi 2SE SIDE <br /> ���-�--- FOR Di.PI+RTMF:IT ll5E Ot�L,. <br /> DATE <br /> L1'i•I.?C,1"iION ACCEPTS H:' ) <br /> `' � _ ;'IiASr ITII/FI\AI.,,INsrECTION <br /> ADD�ilG\iii. CO:.:i�..tS: �_— r i 1 <br /> L.i•tic `x.Ci2G "� I\SP£, I\SPLCTI01 Lam( / n /r>"'�/!DATE <br /> INSPECTION BYL �r DATr <br /> •.G1 .+ GROUT I\SPS T3.G:� P�.IJ,i 's0 i,ROuTING AND FItiAL INSPECTION. <br /> CA <br /> L�V 5/731M <br /> �.r <br /> f1 <br /> i <br />