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. , SAN .TOAQI3IN'.,L'OCAL,"':HE DISTRICT'
<br /> r FOF:;OFFICE .USE: .-HEALTH
<br /> 4 ;r 1'601 E. Hazelton Ave., Stocktzin
<br /> f z a Telephone: ' (209) 466�678k .
<br /> . ,APPLICATION POR WELI, CONSTRUCTION.OR PUMP PERMIT. Permit, No.
<br /> . f,. .
<br /> "piI$ PERMIT LXPyIFtES YEAR PROS DATE ISSUER
<br /> Er. .,Date Issued
<br /> ` (Complete':In Triplicate). ,
<br /> t Apnllc eioit fkis re }► made 36' the ,Sint J;baquin. Local Health District for- a permit to construct
<br /> ai d/or �tstull.-the work 'herein AeecriVed. NThis "applldaiien s> made in compliance with San Joaquin
<br /> CounCy Ordinance No. :1862' aiicl the ltta'iles and Ragulations 1o'f. the San Joaquin• Local .Health District.
<br /> JOB' ADDRESS/LOCATION-
<br /> 1 CENSUS TRACT
<br /> �z Qwner's NameY 14,.
<br /> Phidne cp."_ Y4 a Qi
<br /> 'Address • '� Z.3,-5 � ; �� ; ., - -------
<br /> t' 'Contractor's'Naas r ',� - .. , � _ City .'• ,
<br /> tx C License # I'L Phone�S�`�- 3 VXr.
<br /> I TYPE •OF WORK ,(Check)e• - NEW WELL':'/, 7 •DEEPEN /? RECONDITION ~1 '
<br /> d DEST�tUCTIQN` 7- .
<br /> PUMP INSTAI:LATI4N / Ptw REPAIR ' 'PUMP REPLACEI�tENT f`7
<br /> * Othez /
<br /> DISTANCE TO TQ NEAREST:' SEPTIC 'T�ANKt SEWER LINES 4` PIT PRIVY
<br /> -� SEWiG&{DIS'OSALiEI.D . ' CE-SS 'E30L{/SEPAGE PIT OTHER
<br /> 4
<br /> PROP E TY•,: INE - PRIVATE.IIOMESTIC WELL' PUBLIC DOMESTIC WELL
<br /> .-
<br /> TYPE USE ' TYPE OF WELL , . CONSTRUCTION SPECIFICATIQNS
<br />` Industrial
<br /> Cable Fool`f
<br /> }ia:•,of e11` Exeavatian +
<br /> Domestic/p.rivate - '
<br /> Donnestic/p€xblid $.' ,Did,'' of Weil' Casing t
<br /> <.
<br /> _.Priven ! f 6 . hf .'Cosi si
<br /> Y, .Irrigatjon ' % _ g'_
<br /> Gravel Pack ,_ aU�pth of. Grput Seal
<br /> Cathodic Protection �ic�'tarq 4 ;. ' e - -
<br /> ,+ Yh of,,Grout . .
<br /> .Disposal Other `. t'Other',''In€o,-mat on
<br />} Geophysical. 2
<br /> Surface .Sea;1 IInstalled B
<br /> 'PUMP INSTALLATI
<br /> ONs Contractor'
<br /> -'
<br /> _Tm-,of Pomp. •V- '�;�S�' a ter'
<br /> PUMP- REPLACEMENT, 177f . :-State'yWork y ' H.P.
<br /> PUMP ItEPAZR
<br /> E. / State, Wo 9rk .Done
<br /> ' r
<br /> CIES TRUCTiON'.OF WELL `.WY' _
<br /> e'11 Diameter; . d.
<br /> r. Approxitate;,Depth
<br /> ,Describe Material':and P-&ced re
<br /> I hereby` agree to comply:; with.bal.l'. laws and regulations of 'the,�San_Joaquin Local .Health-:District
<br /> and .the State of �Cali�fornis'•_per.taining to- ar 'reguiating twel3 construction. Within FI.FTEEN.DAYS
<br /> f of ter completion. of, my work y on ;a new well,,. 3 rail,..ft rnish .the•,San Joaquin Local, Health District a'
<br /> WELL..DRILLERS REPORT of ttie. .we1l .aitd notify themtiefore pciting..rhe..well. in.'iise... .The above
<br />' infozuiat 'on,ia- .true to their Iii os t of my:;knowle dge and belief;, °;WILL CALL FQ'R.•A,4GROUT.,INSPECTION..
<br /> PRIOR TO GROi7TiN�3 ANb A"=FINAL,;'INSP'CCI`'IQN .
<br /> SIGNED _ t• - �',; f• . °` _
<br /> .. `. w .. . r '- TITLE ,•'� �
<br /> • : '� (D W ,PLOT P•I.AN QN.;REVE.,•RS&'fiIDE) - , . ., - �._t. ; .
<br /> PHASE I - .. �' -, ,�: . -.r.' pNLY•'' -
<br /> f ^
<br />.Al'PLICATION ACCEPTED -BY` • - _ _' . •
<br />"ADDITIONAL -17-79 CAMMENTS
<br /> :PHASE111, GROUT-INSPECTION- s P FIN INSPECTION
<br /> INSPECTION BY r
<br /> ^ DATE
<br /> INSPECTIQb1 BY DATE.- -71
<br /> 5'.1
<br /> y -
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