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PERMIT NO. ♦ <br />DATE ISSUED <br />APPLICATION FOE SMALL WATER SYSTEM PERMIT <br />Code, State of California. <br />Type of Facility Served: <br />Well: <br />Other <br />PUMPS:HP <br />Other <br />Other <br />Transite X •^Concrete Use <br />type-sand-gravel or <br />Date:ovner <br />£Findings: <br />E.H. 124 JDL 3-68 <br />Surface <br />Pump base seal* <br />Treataent Facilities: (Describe method and equipment, i.e. filters, <br />diotomaceous earth, chlorinator, etc.) <br />,AN JOAQUIN LOCAL HEALTH DISTRIC* <br />ENVIRONMENTAL HEALTH DIVISION <br />a permit co construct <br />This application <br />feet. <br />Other: <br />H <br />Well£xl Date drilled Surface Water [ | <br />Depth 5?^ Size Casing <br /> . Double Cased <br />/ ■ <br />//- /</- 4.V <br />_Date <br />Capacity /COG P/^l ^0 <br />e <br />No ( <br /> <br />Special Provisions, It nny <br /> <br />Permit #_ <br />Date Issued <br />Emergency and Standby: (Describe briefly any provisions for emergency or standby during <br />floods, earthquake, power failure, i.e. gas operative generator,etc.) <br />, ^itie /.' <br />Specify <br />- 17 <br />Yes V£S <br />(Plot plan, showing lot, location of wells, pumps and system components, <br />buildings, etc. to be drawnto scale on^^ever^e side.) <br />— Signed ( ff- <br />Application is hereby made to the San Joaquin Local Health District for <br />and use, or use an existing small public water system herein described. <br />is made in compliance with Division 5, Chapter 7, Sections 4010 and 4015, Health'and Safetv <br />Operator/ 7 <br />Motel Labor Camp <br />For Health Department Use Only <br />Address and Location W /Zia/ V' <br />Owner L L4. //py <br />Mailing Address //VE. <br />Sub-div. [ | Trailer Park £3. <br />Resort I I Other: Specify <br />Future Proposed <br />Number of connections present <br />PRINCIPAL FEATURES OF SYSTEM: <br />Source of Supply: <br />Well Log Yes X No Depth <70 <br />Cased to feet. Annular Seal to S/' feet. <br />Perforations at feet. <br />Well Sealing: Surface pc] Pedestal Size y, '> <br />Pump base aeal^^^^y/Cj Gasket <br />Offset with sealed casing <br />Other______________ _____ <br />Mske and Model TOR ~ <br />Automatic Control Yes No <br />Storage: Pressure Tank Pel Gravity Tank <br />Capacity SZS' gal. Steel [3 Wood <br />Location #/- \A/^// <br />Distribution System: Material: Steal wrapped pipe <br />Describe layout A/ Ajjfl <br />^‘y