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tvtlit <br /> Y9 <br /> Z bA^ e,�SAN JO,-QUIN LOCAL HEALTH DISTRICT <br /> �0B.OYPICB USE: 1601 E. Sazeltcm Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 " <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER?aT Parmit No. <br /> THI$ PERMIT E![PIRES 1 YEAR PEtOII DATE ISSUED Date Issued, .29.76 <br /> (Complete In Triplicate). •, <br /> Application io'hereby trade to the San Joaquin Local health District for a,permlt to:constxaal kk ' <br /> application : <br /> or*inatall the work herein described. This a pp is wade„ittcospl3snca with Smii:t00ag� <br /> Ci"nee No. 1862 and”the s 4axI Ra tions of the San•Joagvin AW <br /> Locais Beaitb�Diattitt:; r, <br /> JQ$b AD1) SILOCMON14- CiSEtSIIS TRACT <br /> i .� ,c ��� •lr <br /> h'14' <br /> t,f 4 I _Y,.. i■wiri.Yr� P�./i!� tr���'il�N�l�/�a`� �1_. ',f'F <br /> Address City �. <br /> iCOnCraCCOI: s . License <br /> Naas ii-�3 Phone <br /> vTYPi6; <br /> or wORK (Check)s' NEW WELL'12r: DRBPEN•/7: R$CQNDITION DESTRUCTION"L7 te a* s K r <br /> '•w `r " PUMP..INSTALLATION'0 Pw REPAIR'L . Pump REPLACElE m ��' �_ �� � q <br /> Other Q « <br /> ISTANC$ TO r7AREST t SEPTIC TANK / / _ ,,,R >`� `` "`>'`:"�" '�"�' ► •k <br /> .Si-� -i. SStiEB LIAES 's ± PIT PRZrif '_ �. <br /> SZWAGE.DISMAL FIM CBS SPOOL/SEEPAGE,;Pt= ;OTBEl< ' <br /> INE'- PRIVATE C WELLAss LIATZ _• ai''` <br /> INTENDED USE TIPS OF WELL OONSTRIIGTIOIf TICA'1'IM1$� �r <br /> Y :13f �. P 1 y a r <br /> r Industrial ,Cable-Tool Dia. of Won".Eaccavation. <br /> t/^-Domestic/private 'Dr:LU*d D M° <br /> •Doaveatic/ � Driven Die. of ilal! Cas .,:_�..� � w:..--..:,�...��+ <br /> ' public"y ,.. : �� _ <br /> s I rigation.�x t ; Gravel Pack ;` Depth'of GrcatxBeM� �; <br /> WCaithodic Protection �_ Rotary Type, <br /> Of Grout <br /> _ L`3spasal" Otber Mai! Inforiation.i <br /> gY•r Y'".'- Geophysical - .fF' -"*:"9F.iflp�el y1 <br /> Surface S al I ed t <br /> PU1l0'.IitSTAI•i�ATIONt tractor DZt/ •. ,# ; <br /> 5 i <br /> Type of ." <br /> 4 PUW!.$SPLACEMQiiL7Y S tate Work Done <br /> PUMP.:3i EPAI&Si State Work Done r. <br /> sgs�S'aT rn 04 M R ) M v P d a w F <br /> `DES=ICTION OF.WELLt Well Diaaeter: .ApAro�aate'Deptli <br /> Dsacribai Material and ProcedureUl <br /> "- <br /> 47 <br /> Z heraby,agresito conply�ulth all lore and regulations of the San Joaquin,Local Beal District "' <br /> aid't'he;$tat* of,Xaliforuia' pertaii"S to or regulating.well'construction.. ;�Tithin,l►IPTE� DA?S n <br /> s Pafter cbapletion of y'rork on i new Tre11, I will furnish tine.San:J <br /> oaquin Local sialth.:Dlitrict(a , <br /> FWELL DRTLL$RS,: OKT�bgrtha,rell amd notify them before putting:the.:Tca11 i>liuse.'""T'he above? <br /> infai'a�atioa`e is°'true to•the-ben t-of..my.•knowledge;,.And belief 1:WILL CALL"FOR,A rIIiSPECTION� <br /> 'PRI •'IO G .��A` INSPE ION ; w,. <br /> `SIGNtBD ] TITLE <br /> a ( DRAW P 0!, E SID <br /> r# _ FOR DEPARTMENT USE ONLY <br /> CATIQ.li`ACCMM 3T <br /> , :�, QNAL �i - 'f. ..��/�� i y s .a yr: q •, fiw^w k!'1:a-'".. - <br /> z3ZOif Ei< DATi ". INSP>QGTIOlI ,3Y <br /> -fiJIGY H •� r .-. .z,.. x es.''2 �' x,w 2K <br /> B` <br /> $., r - Lk,'.�: .. ?e.'Ati &K F. .7• �i�5.'" '� , :y4.:'?�Y • , ,. <br /> : : , wfi' <br />