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APPLICATION FOR PERMIT h
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 15CIl E. HAZELTON AVE.. STOCKTON, CA
<br /> Telephone 1209) 466-6781 ;. k
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> .,1 Mal^t)v m.ldn;p Ihy ;fin Jeerurr_ Lural H^allh D'StnrI !Cr lNanr; [U cUn5lruCt WWI inafa'e rhe work herein descfibed.This apphcatiao is ,
<br /> .r•1=,[rrr,l,l r,,nrn%v;h Sar,Jr'3(fwn Cnnnr:Ordrnnnl-e No 549 for•ww;w of Nb. 1862 for well pump anC Inn Rukes and Ftr`tTulatiarw of tile!Sin Jculryu+n
<br /> L,, ,I i3nalt r, urs l'•f' - {� 's..
<br /> r•r -';r.'r:.G:; ( 1...`c-'cam-- .�!f. (�'•�f; /'ft!7 �J �' /Iiot $ire_ •' 1�� PM�...,_._.
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<br /> S7 �lfi1GG� LrcenGr; f:n.`"LrJ_.`t1: 5C Phone 36IPJ 07 �F
<br /> TY"'L 0T WELL'PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION D ,
<br /> F,,PAP INSTALLATION SYSTEM REPAIR (,� - OTHER
<br /> P.51%.'JCE TO NEAREST SEPTIC TANK SEV�'rR I.$NES DISPOSAL FLD.___ PROP. LINE
<br /> FOUNDATION AGRICULTURE WELL _- __ OTHER WELL d_._ PtTS SUMPS
<br /> INTENDED LSE — TYFI OF WELL AREA CONSTRUCTION SPEC4FICAT#ONS C�
<br /> In=r.;;tnal Oona Bottom Manteca Dia. of `Nell Excavation _--- Dia, of Well Casing
<br /> n(,• r pf,�'I. Gray.il Park- Frac. Tyrx>o1 Casing-_--- SV(R Cifications r
<br /> Pub4r Other Dnita Depth of Grout Seal -- Typo of Grout L— _----
<br /> 1'"a•+17•' Appmi Cen;h [:stern Surft,re Seal instalted by
<br /> Dnr,r Type of Pump H �. _ Stale Wort. Dont
<br /> 0,,,•.uC,rc,) Wn01 omme;f.r _ St!nhng Matrfi31 [lop 50'1 .,� ,...
<br /> D^uch FIVel Mafrnal ln,gtnwa0'1
<br /> •"E JrSfa'i IL L':ORK NEW MN rALLA f 10•J HEPMRfADt)ITION DESTRUCTIONIND sr!r+rlc eYNtern Ir.•.+•rtt(1d if pubLc s!•wef i5
<br /> available v.,ihin 100 fee.t.l B
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<br /> N..Irn:u. o! iro,r,[; unit. 1M only,, n! !,n:l,nco,+
<br /> C f=,. 1•'.{rt 71 rr�l .:r r.�'"l•-:h of 1 foot' _ .... _ Water SabIB depth i C
<br /> ,r: Tl�, rel:s: Tyl;n.",i}q Cllj)ar'tV- No, Cwiijnrtn.,tntt
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<br /> F;:n4il+tine F;of+•'•iV Ler+.n [7r[!
<br /> 11•r=r=.r•v r r r7rlt 1 1'1'v pn., ,•11 ;1•'•:: Irar,•;rap;.aril 'hilOhn wolk will bo don,ul aCro'dan•'c wilh'San Joaquin [aunty orOnance5, State Laws, and
<br /> ,"'td '•'rulatin=rt .. ;hn Srr=1 Jr. ' Lural !+p,r';h D!.rrrt
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<br /> �•"31,IF1y,,y 0t;GVI'.r•1 Gtirlr rnHnnr'= n•;'• hr=rnrhr.t,tlr=nrt lo wn,knlsn.ron,(w••,G,ntion laws of Cahfo•nan " Cnn;rnctoi's hiring or tuh-contrarfinq signature
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<br /> 7�IiS r-rn• !r141 Si trlr ,11! t][7t,1 rr _ �_[ :G- I,,.t,r;-I,I=+•r` f{I,7yVlnq i,n I(•ynr,;f. irflA. �.
<br /> r 1 t • $ f It�� -�L.-����.1..��•+._.`� 1�`II'r ������.� _ e.... Datil_ ,_ ._ _
<br /> VVV FOR DEP.ARTMENIT USE ONLY
<br /> e;.1;t�,:;r[,n Arrr.r,•..f1 dry 1 ._-�.�� 2� VD:ltr ��..�' ..-.V� Area ±_._—___ :)
<br /> ! r:rrihl Ir,ery,rtrnn by J2 'f� — �u�Datr �:!-; 7
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<br /> r•> I.r1i r 71 L•�! v n y',;t :^cit R'3 i 1(11 Traty &15-631 i !CGyi T /L
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<br /> 11^r' A VO LT nt_MI•Tr C7 -� !CR■�«... fzECr.IL'f )13Y DATF; PERMIT NO
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