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Page L of 1 <br /> % SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E . Hazelton Ave . , Stocktjo <br /> Telephone : (209) 466-6APPLICATION FOR WELL CONSTRUCTION <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE I <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distr <br /> and/or install the work herein described. This application is a <br /> County Ordinance No. 1862 and the Rules and Regulations of the S <br /> JOB ADDRESS/LOCATION.4�"_ <br /> Owner ' s Name <br /> Address ,-16, <br /> Contractor ' s Name 4D'L� Lic <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other / / <br /> DISTANCE TO NEAREST : SEPTIC TANK SEWER LINES PIT <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEE] <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONS' <br /> Industrial Cable Tool Dia. of Well <br /> Domestic/private Drilled Dia . of Well <br /> Domestic/public Driven Gauge of Cas.- <br /> Irrigation <br /> as:Irrigation Gravel Pack Depth of Grol <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Inform: <br /> Geophysical Surface Seal <br /> PUMP INSTALLATION: Contractor <br /> p <br /> Type of Pump <br /> PUMP REPLACEMENT : /5Fr State Work Done Pe_ " <br /> PUMP REPAIR: / / State Work Done <br /> DF..4TR11( TTom (1F WFT.T.c WP11 ninmatar <br /> tlIC-11 'DOCuments and Settinas\mescotto\Local Se[tines\Temp\DMCI\D00\2.JPG 11/25/201; <br />