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XJ!4Tz � _ e trf T �r 4 ♦, -�y i �:1> F y..�.. <br /> . 'i• j^4 .fir t t. .r a.-�f t ' -t4'. <br /> '7; $ �L,�f3^�:xh§ � :..,•+� ��L' r Y r� t. " 7t�� �M -� ' s � tix,�x •A� �' . <br /> .,t'? h.3.�''�'" �K.:qP ti.1- tI-j''�►3Kj .�l��r� r ,.'> a,� .�;'�.•�.'f �- £� � y'.t}'� 1 ... .. -., <br /> �st / SAX JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF. E USE: 1601 E. Hazelton Ave., Stockton., Calif. <br /> Telephone: (2.09) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUi.P PERMIT Permit No.7 -Goy 4/ <br /> THIS PERMIT EXPIRES_ 1 YEAR FROM DATE ISSUED Date Issued X7,1— s' <br /> (Complete In Triplicate) <br /> Appliration is hereby wade to the San Joaquin Local. Health District for a permit to construct <br /> end/or .install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 aid the Rulas and Regulations of the San Joaquin Local Health District. ` <br /> r . <br /> i0B ADB;ESS/LOCATIONI 1� / _ ���6Y1 CE13US TRACT <br /> Owner's Nan» l/L� w Phone <br /> Address 7t=✓J9 �?� /. — City <br /> ` J <br /> Contractor's Named License 1 Phone <br /> :tin_ ����• <br /> TYPE_ OF WORK (Check): NEW 1-MLL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION �T <br /> s PL'PL" INSTALLATION �_/` PUMP REPAIR /7 HUM£ REPLACII4�1T ` / f <br /> Other /7 <br /> ---- <br /> DISTANCE TO NFA: ,x: SEPTIC TANK. d[2222 SEW2R. LINES PIT PRIVY i <br /> E!WAGE DISPOSAL FIFLD ��e, �, CESSPOOL/SEFPAGZ PIT S OTHER <br /> _ PROPERTY LIl e - PRIVATE DO-41E•STIC WELL — PUBLIC DOMESTIC WELa. � l� <br /> INTENDED USE TYFr• OF WELL � CONSTRUCTION SPECIETCATIObS ` <br /> Iniivatrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal 0\ <br /> Cathodic Protection Rotary Type of Grout V <br /> LiSrosal Other Other Inforration <br /> ;eophysical Surface Seal Installt:d BY: <br /> � t <br /> — , <br /> PiT:1' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> J <br /> PUMP P_FP_T k .-Z"4 ENT: / / State 7dork Dore <br /> PU:sP 'MPAIR: /7 State Work Done <br /> ' S-TRUCTION OF WELD,: Well DlaT-ter _ _-� Approximep a Depth 1:k <br /> t <br /> Describe Material and Procedure <br /> I hereby sgree to comply with all laws vzd regulations of the San Joaquin Local Health District ?iaP <br /> and the Si-ate of California pertaining to or regulating well construction. Within FIFTttFJJ DAYS s <br /> 21 after completion of my work on a new well, I will. furnish the San Joaquin Local RI-11th District • ;+ <br /> WELL DRILL01S REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO _OUTI.G N INSPECTION. <br /> 'r <br /> SIGNED �f/ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> + FOR DEPARTMENT VSE OYLY <br /> PHASE I �_ a <br /> APPLICATION ACCEPTED BY .� DATE <br /> 7'.DDITIONAL COMN.ENTS: �— �� cL _ <br /> PH_1Si II G t'.`T INSPECT ION — PHAS I INAL INSPECTITYn <br /> INSPECTION BY DATE INSPECTION B3. DATE <br /> L H 142E Rcv. 1--74 <br />