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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Haz--Iton;'Avd-.'i,.'SVock"-ori, Calif. <br /> Z APPLICATION FOR WELL CONSTRUCTINJNOX PUMP PERMIT Permit No. <br /> 2Z� <br /> THIS <br /> 01 <br /> Applicattod,t�id:)h&rqby)-=du,ite bheoSa11aqJb4qutn Loaab Ild al�h- <br /> and/or install the work herein described. <br /> eldlza", xsd-ja vac; fyu_x.p-�y <br /> JOB ADDRESS/LOCATIO4�*00 81119 no-H I <br /> Tuqo W <br /> fga.o pij:nJ fbk-, ncj ln�.o ;-I�r�ja <br /> Owner'daNamso_ <br /> od -Ir <br /> Address . 13 I'd We LCit .51-Ank-1 <br /> Contractor's Name Fiecf:cl HO 7L4y-. Cd_ 'Te Licese7iPhon'e, <br /> TYP4 OF WORK :(Check) NEW WELL,'/ DEEPEN '/ RECONDITION DESTRUCTION <br /> PUMP"INSTALLATION' PUMP REPAIR PUMP REPLACEMENT._. <br /> ..........i <br /> TTSTA N C E TO NEAREST:­­SEPT1C:: TANK";.... SEWER LINES' ' PIT PRIVY--',- .... .. <br /> ..8EWAGE; DI: <br /> $P.O$,AL ;FIELD:-.. . ,CESSPOOL/SEEPAGE. PIV. OTHER: <br /> INTENDED <br /> -USE-:....... ........ .-TYPEOF WELL 'CONSTRUCTION-SPECIFICATIONS <br /> Indiis trial:- ..Cable Tool Did—of Well..Excavation- <br /> Domestic/private'' : ; Drilled Dia. of Well Casifig <br /> D bme'stid/Publiid Gdidgd of: Casing <br /> Irrigation::--; <br /> . ... ... Pack--, , .De-P: th:L of,.Grp'ut...Se4l, <br /> Other Rotary : <br /> Type of Grout <br /> Othei' '"Other: Information <br /> t <br /> , <br /> PUMP <br /> nf6j:&ati6hPumP INSTALLATION.- C&iitr ac...to r _7 <br /> Type of Pump- H.P.,,. 7 <br /> PUMP REPLACEMENT. State-fork Done <br /> PUMP REPAIR: State Work Done boa// !,2 91 <br /> A0 v �.reAn Yr ;r 4200 <br /> J.DESTRi]CTIO N .OF : <br /> WELL:. , Well DiametiE.ir <br /> Appfroximatie Depth er,<Ce, r <br /> 7 <br /> D"cribe Material and: Procedure <br /> . ........ . . <br /> PI hereby agree: to. comply .T;iith. all laws and regulations of. the San :JoaquinLocal Health -Distric� <br /> , and the- State, of! Callfornia plertairiing to or regulating well construction. : Wi: hi; FiFT-EEN�DAY' <br /> Within S . <br /> &ij a IL Will <br /> of ter 'completion' of! work new we"ll furnish the gan 'Lioa'quin L��cal' H6alth Distrj'6t <br /> : my 0 <br /> WEL� DRILLERS�l REPORT. of..the. ;�ell- a-ad notify them before .above <br /> putting the well ir� use.. The o, <br /> information is true to the best Of :;M'V knowledge; and belitt f. <br /> ;TITLE <br /> rSIG�ED .. Q ') .... <br /> 4 4 j9DRAW PLOT PLAN ON REVERSE :SIIjE) <br /> L V <br /> OA, DF/PARTMENT USE ONLY <br /> PHASE I <br /> ACCEPTED BY DATE V/7 <br /> APPLICATION : ' <br /> , ADDITIONAL' COMMENTS; <br /> PHASE !I -GROUT INSPECTION, <br /> PHASE 11j INAL­INSPEg1q� <br /> INSPECTION- BY' DATE INSPECTION BY �c1 DAT <br /> BALL F-OR A' GRO P m <br /> AND FINAL INSPECT <br /> E H 1426 4/72 IM <br />