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µb SAN JOAQUIN LOCAL HEALTH DISTRICT �- <br /> 1601 E. Mrtelton Ave., Stxkcon, Cal!(. <br /> yOF.OFFICE US&: Telephone: (209) 466-6781 <br /> APPLICATION FOR JELL CONSTRUCTION OA FOS" FER"T'r Pert No. 27./UL <br /> FROM DATE ISSUED Date Iaeued X' J3 Z7 <br /> THIS PAIDCIT EEPIRES i YEAR FA <br /> A4Y .I <br /> (C let <br /> In ' iplieaee) <br /> llcation is Sade in e, Plianes rtth San Joageln <br /> Application L 5era6y made co eke Sao Joaquin Local Health Oistriet for a PRO <br /> CO construct <br /> a,d/er install the wrk herein described. Thie app <br /> Counry Ordinance No. 1862 and the Roles and Regulacioas of the San Joaquin Local Health Dfa[r ct. <br /> �(,,,a Ord TRACT <br /> JOS ADDgE55(LOCATLON , �^ ^� ` <br /> ' �N�gtO IEoa Ord <br /> Owner's Name <br /> City Q I <br /> Address ) y7 <br /> ,� ' 11/ �/ T'c - Licanee ez2tiu Yhe� r-siSt <br /> Conctac[ur'a Naee <br /> TYPE O•F WORK (Check): NFd WELL {[y _DEOP� J? 'EDITION /� DESTRUCTION T L7 <br /> pipes INSTALLATION LJ PUte REPAIR L� PLR[P REPLACEMENT !_: <br /> Other J / <br /> SEPTIC TAMC SEVER LINES PIT PRIVY <br /> DisTAACH TO NEAREST': - <br /> CESSPOOL/SEEPAGE Fly __ \ <br /> SEVACEIDIS OS1JL. Flax Pra LC S IC Y LL <br /> PROPERTY LI PRIVATE DOMESTI STRUCTION SPgCLFICATIONS <br /> INTENDED USE 'TYPE OF WELL r <br /> Cable Tool Dia. of Well Excavation q <br /> ' Lndwtrial Drilled <br /> Dia. of Well Casing <br /> ,, <br /> ` e Dostit/pcivace ;Driven Gauge of Casing <br /> Irrigation <br /> 11< <br /> lrrigaLF P t Growl Pack Type of Groutc-Seal <br /> _Cs[hedlc Pro[lc tlen �_ Rotary Type <br /> r Lnforuatiaa �. <br /> Disposal <br /> Other S rface Se 1 to tellad S = <br /> { `-J Ceophyefcal <br /> I ti,ow I< R.P. <br /> PUNP IMSTALLATIO".. �OY lvmP <, - <br /> f �� State Work Dane <br /> I PDetP REPiACENEINT: L <br /> 1 PUMP REYAIR: -L- Seats Mork Done f <br /> Approximete Depth (, <br /> ➢Eg TRUCS Utwell eseur <br /> Dell iMeter-J.1 and Procedure <br /> t h<rehy lsgcei to campFy with all Lays and regula[iana of the San Jeequ n Loca Hoa cfi DLtritt <br /> MYS <br /> work Oa a naw well, hill.furnish-the San Jopquin Local Nealeh District <br /> . ars! she SNca of California: partaln4og cd or regulating we11 constru<t4am. within FIFTEEN District <br /> after completion of mY <br /> WELL DRILLERS REPORT o4 site veil and nknowLe48e®andbefore <br /> belteft. 1tg�LL CAL <br /> FBRuAA GROUT sINSPECTION <br /> informaeiw is arae to the e t a ,b ; <br /> •PAWR TO :C U A F Ifi SO't-- / _� TITLE <br /> SIGNED ,. CRAY PLOT PLAN ON gEVERSE-SIDE . . . - . <br /> FOR DF3ARTMEAT USE ONLY . <br /> P1fASE I G� DATE apB �7 <br /> . APPLICATION ACCEPTED BY p III F 4 IMSPECi OA <br /> ADDITIONAL CONONTS: DATES : <br /> P1USE II G UL7EEGTI INSPCC'TION eY ����jy <br /> INSPECTION RY -__ 1177 CAN <br />