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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton.,.Av&,. .."Sgocktoii, Calif. <br /> Telephone., <br /> APLICATION FOR WELL CONStRUCT'IDN.AOR PUMP PERMIT <br /> Permit No 753 <br /> Z2i <br /> THIS PERMIT r64rl <br /> `),j c_v-1 q <br /> bh1acqa9V06au�LnkLod�ib Ad,;�flflh, Db6f3ji0t�1f*r.na25tS)Vf Alt I <br /> q <br /> and/or install the work herein described. Thiidf.,zp�11' <br /> :Vith 1-S-An',16-aquin <br /> County o0.:r.&inanoeo]qa-,q1862 matd�zhdaRuke-.i;landf- - uViaft 06f-dblTe San I <br /> JOB ADDRESS/LOCATION 1205 Paloma .M49NatsloTRACT io �-,ji;.Joe <br /> F 0 i b D Q <br /> Owner t9JNim(90_[ In t-i6lbldl I&- r4i'Woc'U t,Vg­ q . f 3 <br /> �rd a .4 <br /> Address 11.50 W, gobinho <br /> ad., Driue <br /> Contractor's Name 7ta 1eu Flartr_ig Motor Co. In.c. License #193974 -Phone464—Z <br /> _32 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION —7 <br /> FT- <br /> ' PUMP INSTALLATION PUMP REPAIR REPLACEMENY <br /> d77 - �r i n.Q. U iq tO S.,T.- Co. SpeCtftc.a.ttons <br /> DISTANCE TO NEAREST:: SEPTIC:,TANK , : SEWER LINES <br /> PIT PRIVY - <br /> SEWAGE: DISPO$AL .FIELD . CESSPOOL/SEEPAGE PIT <br /> OTHER, <br /> INTENDE)) 'U$E TYPE OP WELL ' <br /> CONSTRUCTION :SPECIFICATIONS <br /> Industrial: .. .. .. .: -Tool Dia. <br /> ------- of Well.Excavation <br /> Domesti'c/private: Drilled Dia- a - <br /> . of Well Casing <br /> 'Domes ti�_-/g!dblid Dkiven :'Gauge: of Ca�ing <br /> 7--7– <br /> avel �Pack. .� Depth' of; Grout :Seal <br /> Irrigation: r <br /> Other Rotary Type of Grout <br /> Other Other' Inf oimation <br /> 7 <br /> PUMP INSTALLATIONz Cbfitrictor <br /> Type of Pump <br /> PUMP REPLACEMENT: 9'tat'e' Work Done <br /> PUMP <br /> REPAIR: State Work Done <br /> .PUT L; . ;Well Diameter Depth <br /> DESTRUCTION OP WELL: Approximat�_ <br /> :Describe Material and Procedure <br /> , I he'reby agree to comply with. all .laws, and regulations of the San Joaquin Local Health District <br /> and :the State of: Californl;a P'ertain'ing to or regulating well construction. Within FIFTEEN :DAYS <br /> after complet1' onof,'my­wor';k on a new W_e11,­I will furnish the San Joaquin Local Health Distri'CE a <br /> "WELLDRILLERSiREPORt of the well an:d .notify them before putting the well in use. The above <br /> inf o',rmation is tkue: toi;the b6st .of pyknc;wledge and belief. ' <br /> SIGNED TITLE <br /> Workman <br /> - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -7 2_ 1 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT <br /> 1IMSPECTION PHASE II—I/ <br /> XINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATI; <br /> CALL .FOR A GROUT INSPECTION_.PRI9R JO GROUTING AND FINAL INSPECTION. <br /> 4- <br /> E H 4/72 Ar <br />