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1 x <br /> ZN1' <br /> `f^ {i.�'C7'rk:�, eX �Yn?r��J�v"'rw+� •. ,,, 3 /y�yea��,. <br /> In <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDH�OFFICE USE: Y 1601 E. Hazelton Ave., Stockton, Calif. ; <br /> Telephone: (209) 466-6781 <br /> —� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��' s97 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dote Issued, <br /> (Complete In Triplicate) <br /> )application is hereby made to the San Joaquin Local Health District for a permit to coustrneV' <br /> and/or install the work herein described. This application is made it: compliance With San Joa" <br /> Co.m. ty Ordincice No. :1862 and the Rule <nd Regulations of the San Joaquin Local Healtb�District. <br /> JOB ADDRESS/LOCATION �!U?,i' w4-rr.E.-o _ % "el'. 'D4G"� /.nz CENSUS TRACE <br /> (w::cr's Name ��le_ 'G_�a�' E.S.—_ ?hone <br /> Addr6ss L 77 -( 5-F Ti4, 4 fSl T1h��s.czAl f''� I_I / City D D <br /> ?'- Contractor's NameLicense Phone <br /> TYPE OF WORK (Check)- NE'd WPI:' %t�DEEFEN /� RECONDITION �_ / II'35TRUCT20N ,- <br /> TT IP1ST,,V LA'TION /++PUMP REPAIR /� 2lRff' REPLACEMENT .[_I <br /> Phi <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T'ANYSEWEL LINES PIT TRIVY <br /> _ . <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEFAGE PIT_ OTHER <br /> PROPERTY ••APE - PRIVATF: DOMESTIr, WELL —' PUBLIC DOMES3,IC <br /> INTENDED USE TYPE OF I,L CONS'i IVICTION SPEGIFICNTIOWS_ W, <br /> Induacrial _^��'"Ca'bToo- Din, of Well Excavation �F�— !4 <br /> +% *53mestic/private Dvilleli Dia. of Well Casing <br /> Domestic/public _ Driven Gauer of Casing <br /> Irrigation Gralel pack Depth of Crout Seal _ -x7 <br /> ` Cathodic Protection _ Rotary Tpie of Grout E✓r-�G�`�`__ <br /> Disposal _ Other Other Information <br /> -Geophysical ;' SirfaceSeeal Installed B—Y: •' <br /> P09 INSTALLATION: Contractor <br /> Type of Pip J -- H.Y. _ <br /> PUMP REPLACEMENT: L7 State Work Done <br /> FOM4 '.REPAIRt L7 State Work Done <br /> ,MSTRUCTION OF WELL: Well Diameter - Approx!.matc Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all ?.awe and regulations of the San Joaquin 'Local. Has t1i District <br /> and the State of California pertaining to or regulating well construction.. Within PIPTEEN DAYS <br /> after completion of my vork on a new wall, I will furnish the San Joaou9n Local Health District c <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the-beet of my lniowledge and belief. I WILL CALL FOR A G=ROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS . <br /> "IGM ->fc -ie,a+a.� H _ TITLE <br /> DRAW ' L(YF ?LAN ON REVERSE SIDE) <br /> FOR DEPAQTMENT USE ONLY " <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ , _ ,_ DATE _ �4f - <br /> ADDITIONAL COMKZNTSt v <br /> >•. PHASE II GROUT INSPECTION .PHASE II1 PINAL INSPECTION <br /> -=, INSPECTION BY DATE INSPECTION HY_ _ DATES <br /> + 1 E H 1426 Rev. 1-741-74 2M <br /> y ; <br /> .� tip. . �_:�:.,.. ,. ___ ..y_.' s«.•d3tHFeaSdSmleF 7'��.+dc:i <br />