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r OSTERBERG 8 <br /> 160SAN JOAQUIN LOCAL HEALTH DISTRICT 2523 RIVER ROAD <br /> FOR OFFICE USE: 1 E.. Hazelton"Ave. , Stockton, Calif. MODESTO, CALIF, 9530 <br /> Telephone "='(209) 466-6781 -COD OEjeMorr r015- <br /> PLICATION-FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No 7-1?4"A/ . <br /> THIS PERMIT EXPIRES ;1 YEAR'FROM DATE ISSUED Date Issued -77 <br /> (Comp•lette In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862.,and .the Rules. -and Regulations . <br /> PEO <br /> of� the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION if Q !Y/EZ40 CPEO --� tlr-l'POAJ CENSUS TRACT <br /> Owner's Name Z;f4/VY <br /> _/ ( /!f t� �- Phone <br /> Address ����� � G�� �� Citye, 9 <br /> Contractor s,'Name ZAZ572 i E!ARCeC S� LC//q,�T License # j�/7/�Phone,6�;Z-S 4!0 <br /> TYPErOF WORK (Check) :-ANEW WELL * ' <br /> DEEPEN / / 4 RECONDITION /7 DESTRUCTION /7 <br /> Y/ ' <br /> PUMP INSTALLATION - PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- PIT PRIVY --- <br /> �; SEWAGE DISPOSAL FIELD 72.-k CESSPOOL/SEEPAGE PIT OTHER <br /> - - <br /> 1. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> In ustrial Cable Tool Dia. of Well Excavation /a, <br /> Domestic/private Drilled Dia, of Well Casing 134E <br /> Domestic/public Driven Gauge of <br /> Irrigation ' Gravel Pack Depth of Grout Seal 5-0 ! } <br /> Other _ Rotary Type of Grout f',�jl/T• <br /> 0 <br /> Other Other Information �• <br /> PUMP INSTALLATION: Contractor Gzalzd' <br /> Type of Pump H.P. -- <br /> _ a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State f California pertaining to or regulating we�.l construction. Within FIFTEEN DAYS <br /> after co etio of my work on a ney,1 well, I will furnish the San Joaquin Local Health District a <br /> WELL D LLERS PORT of the 1 and notify them before putting the well in use. The above ` <br /> infor ation i -true to the b st of my knotA�Rdni kft <br /> SIGNED �- 2523 RIVER -ROAD <br /> GF.STD CALIF, W TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F PART T USE ONLY <br /> PHASE I ;• Ap <br /> APPLICATION ACCEPT171_1 A(07 DATE 1_7 ' Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRQUT IIJSPECTIOW PHASEI F AL SPECTIO <br /> INSPECTION BY 7 8 INSPECTION BY DATE417 <br /> 10, <br /> CALL FOR A T ON RTOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M 4 <br />