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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Q 1601 E. Hazel tonVAve. Uftock -ori, Calif. <br /> Telephone:: (209)x,1466--Z81 <br /> PLICATION FOR WELL ,CONStRU6TIONAOR PUNA' PERMIT Permit No. 44 <br /> L-G <br /> M-3 <br /> THIS PERMITEXPIRES.,I:LEBARdFROM',DATI,`91 -SS `ODate IdSueff r itr�' �� <br /> `VSs S _ A-S f-t T j+ ,.r.::: .(Cem�1��e <br /> Applicata,cA[,idnh(Breby�made,rto therr8angJ6aguin!no&al- lialah Distriot�fb�t aepermit-to'Icbnstrtiet f <br /> ,and/or install the work herein described. �compjJance-with i,S6nvJ,6aquin <br /> County4;)Qndinanoeo1qo gl862nTaAdythe!.RutegbandBRegulAbif6hsn6fdthe.:Sari JJ{Oaq,uih.:�Lodai-�,Healt'hjDi,&frictt <br /> JOB ADDRESS/LOCATION �IIm� 6a.r �lD u ,� / sQ �c.A •.;c.CENSUS°TRACV. .f <br /> 4 tl.� �!h To y _ o_--q s :10 ��;a» �k �C3 � Clt t Y i'. rr3 v1 _ 3 F rid:. '.[c+ <br /> Owner!aaNam610i l <br /> �• :i "7:1:•j�� rt17.�.i'lr.C:�;'r> ISi': .:t._, �'7I' it'��:C?("-;Pf�on�,=y7_'i` `�'O'e'Ga0 '.l', .U' <br /> Address <br /> `�-�--- .��.�.,.... - ✓._ __.W___ .._ ....._ Cit ,/ <br /> Contractor's Name <br /> i License # ' �-i'7hone <br /> 76 � <br /> _ Q <br /> TYPT{ OF WORK (Check) : NEW WELL '/% DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> € OtUhMePrT/SALLATION :/X/ PUMP REPAIR /`7 PUMP REPLACEMENT / <br /> T <br /> ...... <br /> .' :SEWER EINES" <br /> DI5 ANCE TO NEAREST: ...�SEPT TC` TANK . ' .. PIT PRIVY. .' . <br /> ; .. SE WAGE; DI$PO$AL.FTELD _ CESSPOOL/SEEPAGE PIT.. . . OTHER t <br /> 'INTENDED..USE .:... .. ........ TYPE OF WELL <br /> CONSTRUCTION'SPECIFICATIONS <br /> Industrial.. .. .. .:. . .... .. ... . .. . .Cabl. Tool . . D.ia....of. -Weld..-Excavation <br /> Domestic/private; DrilledDia. of Well Casing E <br /> 'Domestic/publidniraven Gauge' of Casing <br /> Zrrigatior► ......- .•..... .._ . .. :... .. : . ...Gravel .Pack . . .Dep.th,; of.. Grout:Seal . <br /> Other Type <br /> ,Rotaryof Grout <br /> - -- <br /> Othdr O e o <br /> th r:.. ma 1 <br /> nI f r t'on <br /> v � <br /> aPUMP INSTALLATION: �Coritract6r <br /> .,.Type of Pump. f4F H.P.' <br /> PUMP REPLACEMENT: /=/ $tate Mork Done <br /> : State Work Done } , <br /> ,DESTRUCTION OF WELL: .;Weil Diameter . Approximate. Depth. s <br /> , Describe Material and Procedure <br /> I heireby agree to comply -with .all laws and reguiations 'of the San-.Joaquin Local Health District <br /> and1the State, of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion• of my work on a new well, -I will furnish the San -Joaquin Local Health District a <br /> WEL> DRILLERS. REPORT. of the welland- notify them before putting the well in.use. . The .above <br /> information is true tothe best .of '.myknowledge an, b?-lief.;I <br /> SIGNED E .. .. j <br /> f` V (DJAWIPLOT PLAN ON REvQgE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> } <br /> APPLICATION ACCEPTED BY DATE F -1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION- PH44M III/FINAL INSPECTION. ' <br /> INSPECTION BY . -DATE INSPECTION BY_- - DATE -2-cl- <br /> GALL F'OR A GROU_ ;NU E,�TION PRIOKTO_GROUTING AND FINAL._INSPECTION, _ <br /> E H 1426 4/72 IM <br />