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SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave. 4:Stocictoi-, Calif. <br /> Telephone:.-";,.(209),44W'6781 <br /> APPLICATION FOR WELL CONSTRUCTIGNAOR PUMP PERMIT Permit No. 7q`.116 Ir! <br /> i <br /> THIS EERMI ;:BXPII $S'L': ' AF `iF1McI?ATE�3cST�El3kr�t3 t .E[�DL3�-;Z��� e�' i�% ` –7C <br /> :c„�� !-;:.;.{COmp�:at� �#Cx�T�`$p��Ha��� �rx.� r.i:�} xv3'.ra.�cj'Se �.€x �� r��•t�.._:S�s . � <br /> Applicatged'blAfC mdrp,b,y,7 de,-ltto bheo4aa-,jJbaqui'x !Bada o I1darl.d} al atV 3f t.. f�� a z#z iT=std” or 9'trii .t7 .` j <br /> and/or install the work herein described. Thifsa:-ap]rli'Calio'mvigbmade,ii�&:compIflAncezwitthl,Sgris✓Joaquin I <br /> "Joao ct:`CountyArAd-zai c9o4gl86,,2 c�e Satia <br /> -51r11220q �f:7ji Zo 1�f-Al3 70 off:"qav C. <br /> JOB ADDRESS/LOCATION xscsCEF3S8ra.71RAT„:.Cr s�x'i.c:e <br /> .• °Y!3C}vY ^fY.'t� �lf3 '10V Y33L�hE 3{fl dS0 -Q 2:: l -[i -j <br /> u iildfw vis_9SF "13111,0 JC) <br /> Ownera9- All&0 iT f7° 11ld -Z flo f3S_ijay'n, <br /> + a <br /> Address <br /> Cit <br /> y__ __ ..G <br /> Contractor's Name _ _ . w License #%&02j Phone v� 6 <br /> i <br /> _ s <br /> TYPE OF WORK (Check) : : NEW WELL DEEPEN/ / RECONDITION /-7DESTRUCTION j <br /> ' PUMP INSTALLATI / PUMP REPAIR /' / PUMP REPLACEMENT/ <br /> 1.0 <br /> DISTANCE TO NEAREST`: 'SEPTIC-TANK - : - SEWER LINES• PIT PRIVYV <br /> SEWAGE'DISPO$AL ,FIELD . . CESSPOOL/SEEPAGE PIT : OTHER: �— <br /> I <br /> INTENDED USE' 'TYPE OF WELL ' CONSTRUCTION .SPECIFICATIONS j <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private; Drilled Dia. of Well Casing L ++�� <br /> 'Dome.sti'c/piiblic Driven ' Gauge' of Casing P V <br /> Irrigation, Gravel 'pack Depth: of,Grout .Seal U2 rr . <br /> Other Rotary Type of Grout er C-Af T` <br /> Other : Other' Information ' ! <br /> PUMP INSTALLATION: `Contractor i <br /> rType of Pump H.P. i <br /> PUMP: REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Dane <br /> .DESTRUCTION OF WELL: :Well Diameter ; Appro imate Depth <br /> T :Describe Material 'and Procedure <br /> I hereby agree to comply with all laws,. and regulati ns of Ahe San Joaquin Local Health District <br /> and the State: of California pertaining to or regulating well construction. Within FIFTEEN DAY$ <br /> aftelr completion of:my:woik on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the, well and notify them before putting the well, in use. . The -above <br /> information is true to the best :of :my know'ledge. and belief. <br /> SIGNED P!2TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR- DEPARTMENT USE ONLY <br /> PHASE I V <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASWtl GROTJT INSPECTION. PHASE JWINAL,4NSPECTION ' <br /> INSPECTION, BY DATE =- INSPECTION BY _ TE r- <br /> f <br /> GALL FOR A GROUV IN,SPE ION PRIORTOGROUTING AND FINAL_TNSPECTION � <br /> E H 1426 4/72 �1M� <br />