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� r SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: /��1601 E. Hazel tonf':Ave. ".Stockton, Calif. <br /> Te1ephone.:1,;.(2:0'9)'>'r-4bb=-'6781 <br /> APPLICATION FOR WELL UONStRUCTI'O V-OR PUrP PERMIT Permit No. <br /> EXPI�tES,,�' E 1 t:3FROM;DATE,)ISSUEDi - �`f � <br /> THIS PERMIT Date Issued -Z` -7°7% <br /> 'yn"� r'Ts��' F �•��Iilp•�.�:�e ;j�a l'�°�'plicate) � \s ., "£r3i� "f .: i•. sit3 +- '��� } <br /> Applicat*,Qn«i5:,)hbrebyxmade•s:to ,the5SatgJ'oaquxa1LbLai Health District!fbr.!%a,�Peimit'�-to`%caristrdcE �- <br /> and/or install the work herein described. fih 'sp .licC 'ntz'va :made inr:cot�?pance s�aith -San`�3oaquan <br /> IIC++o/u�nty:�b_rdina/nye'e,r)No'.t;1862r�and't.'hir,R ilei rand ,Regula." +:airs:}ci.fr the,San)Joaqu n -Lacagl/'�'Hei dl�thAD strict: I <br /> UU fit. ,� J,,�`'? "r.', c c n' -� �"'.,', /'�"�`'� '�;7-1.f. . <br /> JOB ADDRESS/LOCATION soGENS13Sa,TRAACT10 '�;z <br /> ...s •+ c, °' - �: * - - �. ..{e i3,;.£' � {'..'!'i � r~�o? r ..`yi -IF.'•°� i'; :i.3a.;.`.i i ._I ' <br /> .'�..t;f��}'i:•S.^x Y.a:�i:'�3�'l:..? �fA � `.� <br /> r r :x r, ° ii .{" : i r.,• t•. h a i 4 - t ei. r, rf-'• d ) ). .!S <br /> Owner.sNamdOr. ;�o r,za Lai�9r. E1L�f e . .,c� ra � t - r.r} x �K �: �:,r_.P2iorie•- n15_,. <br /> Address c_ City_•._ <br /> Contractor's Name .x�i -�, License ����f 2 Phone <br /> DEEPEN / / RECONDITION /� DESTRUCTION <br /> TYPE OF WORK (Check) : ' NEW WELL 13q, <br /> /? <br /> PUMP­INSTALLATION / /' PUMP REPAIR '/' / PUMP REPLACEMENT /-7 <br /> y Other! <br /> 177 <br /> a <br /> DISTANCE TO NEAREST EWA GE; DANPQSAL .FI SEWER LINES ' �r PIT PRIVY <br /> ELI? 7�. CESSPOOL/SEEPAGE PIT. ,— .. OTHER -- <br /> INTENDED- -USE • TYPE-.OF..WELL" -CONSTRUCTION' SPECIFICATIONS . <br /> ' <br /> Domes <br /> .. <br /> .l ....... .. ....:.......:. .. ..: . .Cable Tool Di ..a' Pf .Well Excavation <br /> u <br /> st .c/p ate Drilled Dia. of Well Casing /per <br /> Dome's tic/public D"riven' <br /> Gauge' of` Casing <br /> Irrigation . .. ..� :_-Grav'el:Pack meq.. :Depth, of -Grout. Seal <br /> Other Rotary - Type of Grout <br /> Other Other: Information° i . <br /> 'INSTALLATION <br /> . : . . :. . . . . . .. . <br /> i <br /> PUMP - N: Contractor <br /> ' Type...Of Pump t - _ <br /> H,P. <br /> PUMP REPLACEMENT: .. Sta6e14ork Done_ s <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELT.:.:..: We71 .i3iameter. ..Approxi:mate Depth.. . . . . .:. . .. <br /> Describe Material `and Procedure <br /> I hereby agree to. compl.y .with-all. -laws and regulations of the San Joaquin Local. Health..Distric;t <br /> andithe Spatepertaining: of California ertainim to or regulating well. construction. ; Within FIFTEEN.DATS <br /> after completion' of:, my work' on' a' new w4.ell, I will furnish the San'Joaquin Local Health District a <br /> WELL DRILLERS: REPORT. of- the well and notify them before putting the well inuse. . :.The.-above- . <br /> information is true; to; the best',of my knowledge. and belief.; <br /> • TITLE: .:... . .. ...'.. <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; <br /> t <br /> PHASE I :. <br /> APPLICATION ACCEPTED BY DATEi�Z - '- <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTIONPHASE II/FINAL `INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ 0.5'X73 <br /> GALT. FOR A GROUT INSPECTION PRI(3R.�0 GROUTING AND.FINAL INS ._. .._IQN• � <br /> E-H".1426 4/72 1M v... .._... _. �. C <br />