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3 tl SAN JOAQUIN LOCAL HEALTI, DTS <br /> �-> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, CaliZT f. <br /> Telephone: (209) 466-67$1 ��� / s <br /> w <br /> fa, <br /> �++ APPLICATION FOR WELL CONSTRUCTION OR PUMP PER"aT Pernik No. ��'�4,d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> `- ISSUED Date Iaatu.u"� 71 <br /> ' ' (Complete In Triplicate) e <br /> a r <br /> Application is rereb, ' -de .to the San Joaquin Local Health District for a parudt tv conotrtict ` <br /> and/or install the work herein described. This application is made in compliance with,,San'',JwKuin !' <br /> Y :,z County Ordinance No7 1862 and the Mules and Regulations of the San Joaquin Local Health.District. <br /> IFk 4„ 'r ` .FOB PDDRE� 2LdCI�TI/(17�1'q.5)Qnorth of Hioray 12 , <br /> CENSUS TRACT <br /> + nn 5 owne .T R Nruoe M-`' <br /> rpt {� Phone <br /> r <br /> Addrass <br /> rTF` Contractor's Name <br /> r y, DritiersLicense #24010 Phone 88 <br /> yV Fs TYP3 or WORK (Check)t NEW WELT, ' <br /> ' nye, DEEPEN /� RECONDITIOW / f DESTRUCTION <br /> ' PUMP INSTALLATION REPAIR 1_7 PUMP REPLACEHENTi <br /> Other -7 <br /> DESTAN ECSC TU NPARE3'T $EPTIC TANK --4� <br /> 4 SE9IER LIMBS PIT PRIVY ���" <br /> SEWAGE D7ISPOSAL FIELD 2501 1. <br /> r c. CE <br /> Or=PIT <br /> r 7'k PROPERTY LIRE - PRIVATE DOMESTIC 418LL PUBLIC DOMESTIC WELL i ` s3'R:I <br /> ?a n ' <br /> s•y5+ IN'.ustrD USE TIfF'P. OF WELL CONSTRUCTION SPE':,'IPICATION$ <br /> Industrial ' <br /> _ Cable Tall Dia; ;of Well Excavation 7�r��" <br /> ` w• <br /> Domestic/private Drilled Dia. :of Well Casing 3 j' <br /> * 1 <br /> Domestic/public I <br /> g� P Driven Ga'_ of Casing <br /> ,�r, `x Irri tion Crave]. Pack Depth of Grout Seal <br /> x ; , t Cethodii__ Protection Rotary Type-!of Grout <br /> Dispoa ,l Other Other Information � <br /> Geophysical <br /> .:,; :.•. r <br /> r� w _ Surface Seal Insta:iled_ <br /> PWIN:P INSTALLATIO ._ . <br /> _ Contractor :` `• <br /> Type of P,amp — �H.P. <br /> , a PLR? REPI,ACENW: L/ State Work Done ^� � <br /> —-- . . /7 State Work Dane <br /> IS•TRUCTION OF WELL: Well Diameter 10 <br /> Approximate Depth <br /> Describe Piaterial and Procedure ��--- <br /> ., <br /> I hereby agree to comply with all laws and regulatioue of the Sen Joaquin Local Health District %,- <br /> ' x� and=the State.of California pertaining to or regulating v:ell construction. Within,PIFTBEN'DAYS <br /> ;after completion of my work on a new well, I will furnish the San Joaquin LocalF[ealt h`'Dist'' a <br /> ' -ti WELL°DRILLERS REPORT of the well. and notify them before x: <br /> F I infatmatian is true to the•best.of. putting the-well in use, The above . <br /> . # my..kncwledge and belief. I WILL CALL FOR A`GROUT INSPECT did <br /> { II! PRIOR TO GROUTING INAL INSPECTION. - <br /> �I . 'SIGNED, d ---.--� TI' ire< .r ' I <br /> • THE - r.i, T i <br /> r. Y: - _ <br /> ); DRA6� PL(JT :LAN ON RVBI±SE SIDE <br /> LS <br /> FOR DEPARTMENT USE OAL, <br /> PHASE I J. <br /> 4 r., <br /> APPLICATIONYACCEPTEU BY c - <br /> �,:3.: ADDITIONAL. COMMENTS: v t --..__ _ DATE <br /> PHASE'7I GROUT NS ECIION n[3ASE ITL PINAL INSPECTION P <br /> INSPECTION BY DATE IT"5?'EC'fIUN TRI <br /> 4 i DATE <br /> E H 1426 - Rev. 1-74 <br /> � 2T � <br /> f�y 7} #R°! } .liq <br /> �"✓ W j f-1 �p� <br /> i Ca�@oi.'}" �f`..{ 5�r s�'��'q t ?, F� � .J. �,...�, `•r /" � � � V 4 U/ J - <br /> �F Y <br /> r Y <br /> Ai <br />