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c I TOAQUIN LOCAL HEALTH DISTRICT " r <br /> FOF OFFLCE USE: 1601 E. Hazelton Ave , , Stockton, Calif . <br /> _ Ile le phone : (209) 406-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU:',IP PERMIT Permit No , <br /> THIS PERMIT LXPIRES 1 YEAR FROM DATE ISSUED Date Issued �--- <br /> (Complete In Triplicate) <br /> 4pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :Iced/or install the work herein described. This application is made in compliance with San Joaqu <br /> -ounty Ordinance -No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> /l �� rL1 b�Z ��16 r��S% f�,�fG c7-�1c.eje-s 7- o F 7-A*,e.vTc+�1 <br /> JOB ADDRESS/LOCATION acvoo �-_'Sokrt4 o�=` DPY.E'/GS CENSUS TRACT <br /> ?caner' s ?Mame �� �•</A �/.� � __ ---• _ phone <br /> %ddress <br /> on jOuquill 1 511,13 —U, <br /> OnCraCtOr'S Name (Division of Son Joagdn Suip:iur Co.) <br /> H. sact—W-00 License # 31037 <br /> CYP ' OF WORK (.Check) : NEW WELL /_/ DLI:PE^d !_/ RECONDITION j / DI?STTOICTION - <br /> PLIKP INSTALLATION % / PUMP REPAIR / / PUMP REPLACE ENT <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK f SEVER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES°�I'OOL/SLIEPAGE PIT OTLLER <br /> PROPERTY LINE: - PRIVATE T)OrIFSTIC. WE'LL PUFiLTC L'()Mt:S'1'IC: WF.T,L <br /> INTENDET) USE — TYPE OF WEL:, CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable 'fool Dia, of Well Excavation -- <br /> Doiieustic/private Drilled Dia, of Well Casine _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Caravel Pace. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> 'UKP INST a <br /> ALL_.TION: Contractor <br /> Type of Pump H.P. <br /> ?UMP REPLACEMENT: /Matt Work Done <br /> 'LIMP REPAIR: J / State Work -)one - <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth � <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Hea3th District <br /> 3rd the State of California pertaining to nr regulating well construction. Within FIFTEEN DAYS <br /> sifter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> HELL DRIT.LERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the lest of my knowledge and belief . I WILL NW +i �54'L;C.TfUN <br /> _ +i , <br /> 'RIOR TO GR0 ', ' A�D A FTN 11_ It i U (Division of Son Joaquin au'; ,ur Co.) V <br /> 4 <br /> SIGNED _ TITLE <br /> RA14 LOT PLAN ON REVERSE SIDE) <br /> FOR Di.PPN1RTME;NT USE ONLY <br /> PHASE I <br /> APPL ICA`I'I:ON ACCEPTED BY . DATE <br /> ,%DDITIONAL CON2NIENTS: _ <br /> PHASI 11 C.RI?UT Ii7SPECTIOtd PELAS✓ TII/1 TNAL INSPECTION �`, 1 <br /> INSPECTION BY DATE _ INSPI.ECTION BY J� �� DATE 4 <br /> E H 1426 Rev- 1-74 <br /> u.�7 7 2m <br />