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� u <br /> r c r ` _ SAN ,(OAQUIN LOCAL. 11EALT11 DISTRICT 1 ,) <br /> It►>^ OF I,.L USF:� 1601 E. Hazi'l.ton Avc. , Stork!on, t :ilif. <br /> 'telephone: 1209)- 466-6781 <br /> --- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> TILS PERMIT 1'XPIRES 1 YEAR FROM DAT17 ISSUED Date Issl--,lJAk 1797S <br /> (Complete In Triplicate) <br /> Applicrtion is hereby made to the San _►oaquin L,ral Health District for a permit to consttoct <br /> and/or Install the work herein described. This application Is made in compliance with San .Lvaquin <br /> Count-: Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JUB ADDRES:I/LOCATION 610 L31 �L� _ -- _ CENSUS TRACT ---- <br /> Dwner's Name -� - ---- - ---- -- Phone �C•�/• - <br /> Address 5 tmss: ly��:,-- Cit v <br /> 4 <br />:rntracror's Name Phone -� <br /> z=z� <br /> FYPE OP WORK (Check): NEW WELL /tom' EPI:N % RECONDITIur! / 7 DES[RUCTION /_� <br /> PUMP INSTALLATION PUMP REPAIR /-7--PUMP RFPLACF.MFNT <br /> OLller <br />)ISTANCE TO NEAREST: SEPTIC TANK ---SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEI:PAGE: PIT___ OTHER �= <br /> PPI-)PI-'RTI' LINE - PRIV_ATF_DCMI'S'1'IC_ WF:I.1. _ PpRLIC Dt►"F.STI,- WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SI'ECIFICATIO`S <br /> Industrial �ncCable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Uta, of Well CasingV- <br />__ Domestic/public Driven Gauge of Casing - <br />_ Irrigation Gravel Pack Depth of Grout Seal <br /> -- Cachodlc. Protection Rotary 'type of Grour <br /> Disposal Other Other Information <br /> Geophysical - Surf act Seal 1astal ltgd $y: <br />'UM' INSTALLATION: Contractor <br /> Pump Type of tun - - - - <br />'UNJ1 REPLACEMENT: / / State Worl, Done <br /> IZ�- - <br />^UMP REPAIR: / / State Work Done - <br /> I:STRIIC'1'IUN OF WELL.: WeII Diameter _ _ Approximate Depth <br /> -- - Derierlht- Material and Procedin - - �- - -- <br /> hereby agree to comply with all. laws and regulations of the San Joaquin Local Health District <br /> nd the State of Callfornia pertalning to or regulating, well construction. Within FIFTEEN DAYS <br /> fter completion of my work on it new well , 1 will furni.,h Lite San Joaquin Local Health District it <br /> LLL. DRLLLERS REPORT of tilt. well :u►d notify them hefort� puttln{, the well In use. The above <br /> oformatlun is true to the best of my <br /> _jawwiedgo and bolief. I WILL CAH. FOR A GROUT INSPE.CTIOrl <br /> TITLE t <br /> (DRAW PLOT PLAN 0_N _RLVI?RSE SIDE) _ <br /> FUR UF.PARTMI-NT USE ONLY - <br /> I'I'L1CA"I'IUN ACCEPTED BY �. i ' - -4 UA'fE U/' <br /> I►�)I'f'OVAL COMMENTS: -_-_ _ _-_._�---_ .PRASE Ll iI t:h_UU"1'_I"ISI'I:CT►Uti--- -r-� - '- _ .-_,_- PIi115F: .[ FI1' ,INSI'F.CTION i <br /> ItY --- _- -- u�,'f�-- - - [:JSI t:rT I U!I 1i1 � / , '. �.lk►ATE - 4 <br />