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SAN JOAQUIN LOCAL, NEAL7M DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'•Ave. 'i=$Cockto,., Calif. <br /> G i Telephone:F,`',.{20 )'µG6b'y6781 <br /> 44LICATION FOR WELL-PONS tRUCTIONAOX PUMP PERMIT "„Permit No.-]Z- S 3 7 <br /> THIS PERMIT;'EXP LRES;1 L12EAR `F'ROM1,D <br /> (Camp eCe Ih` T1lYn alt;' , 33 r , r `EU xr )f iJ S <br />: Applicat�an#�i���►erahyxmade- ta #�heo�arotc;Joaqui�rn.z"F�o¢� I�e�I��.DisCrictlf�r.�a�erriit�toYo'o-3stltuctF .� <br /> and/or install the work herein described. Thal ' apticat :t�t�. 5'^madam, iccimplii,ce"- rhi7Sn 13oaquin <br /> County FQrd ana*cec4o;rgI862;.aa+tib,t-hdf.Rulyes"bandf;Reguliwtiydns=sof:d e: Sar -X6acTtih-z1 'caD-JHealt.hIDis°tr'•'ict. <br /> n.IdJ't as 0q. x'd 71 D Mf r. ,40 1Y5aI—e< 1,41R'Ogc Z;': °rte"r1 i7 if �iC: f'R� .l£b,?:.: E�Lii:Cr€{'G tj pili s jr'irc i <br /> Ixi3C�T ,c.f <br /> JOB ADDRESS/LOCATION 2 E. Sonora Farinin ton ' a��oCENS�S�TRA�T�- � frac. <br /> .go-xq: vifllYilef? by .To!: �,�`3s$t)'s t� �sd�p ES{3 � r_.a ;�• �� t r fi t c���`�:7 �f�` 1 ^ .t _ <br /> Owner'dr3Nam0.��' ' trtl �Ed� .� i; abwac(a�: rF3: : ! <br /> Address 792 Danville B1 v City 7� y <br /> Contractor's Name € #2Z6187 , <br /> Stant e ? le c t:r 'c Motor Co Inc. License Phone 464-7321 <br /> ' TYPE OF WORK ,(Check) : ' NEW WELL: // DEEPEN / / RECONDITION / / .DESTRUCTION '/� I <br /> PUMP INSTALtATION-'/ % PUMP REPAIR IT PUMP REPLACEMENT / <br /> DIS 'ANCE TO NEAREST: "'SEPTIC'SEPTICkTANK SEWER LINES PIT PRIVY ; . .. ..... <br /> .....• SEW <br /> ' " <br /> .... . . .;., AGEj.DISPO*AL ;FIELD ..... CESSPOOL/SEEPAGE P.IT . . OTHER: } <br /> 'TY <br /> INTENDED VSE <br /> . .: .... ... ._ PE �CableLTool . . Dia f _CONSTRUCTION :SPECIFICATIONS <br /> } <br /> . Q ell.Excavation u; <br /> 4+ 1 Domestic/private; Drilled Dia. of Well Casing <br /> Domestic/pubTxC` Driven Ga:ugei of Casing <br /> Irrigat:ion:.. .. . .. : . ..Gravel..:Pack_ , : . Depth: of, Grout :Seal <br /> l <br /> Other Rotary Type of Grout "! <br /> OdieIX <br /> Other: Informatiozi ` <br /> : PUMP INSTALLATION; Contractor <br /> A j Type of Pump' H.P. <br /> P <br /> UMP; REPLACEMENT.: / / State 1�ork Done j <br /> PUMP REPAIR: /g/ State Work Done ' Pull Pump., re `air and re=install. � <br /> `.DESTRUCTION .OF WELL: Well Diameter Approximate.Depth. { <br /> -- Describe .Material and Procedure <br /> -- _. <br /> � I hereby agree to complyz'ith..all laws..and regulations of the San Joaquin Local Health Distric <br /> ; and .the State: of`. Calif ornia pertaining to, or regulating well construction. Within FIFTEEN:DAY� <br /> after complefon` of my:work on a new we11, I will furnish the San Joaquin' Local Health District a <br /> WELL} DRILLERS..REPORT...of..the. well andnotify them before _putting the well in. use. "The-above } <br /> information ruef o th b st of my .knowledge', and belief. <br /> SIGNED ;TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> t ;FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> ADPL CATION ACCEPTEb BY BATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT FN5PECTION : PHASE hf:FINAL 'INSPECTION <br /> INSPECTION BY - ; DATE INSPECTION BY DATE ,- a.� <br /> .. <br /> BALL F'OR A: GROUT_INSPE TION <br /> PRIOR.TO. GtQUTING AND .FINAL_ PON. <br /> E H 1426 4/72 1M <br />