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r° <br /> /�° SM JOAQU MLOCAL KALTV D I STV I CT� , ? � `* tj _,e fK01 K. VaiAltea Ave.. Sta'htou. LAW. <br /> a _...w .. ._. ._ _ . 'tel*phuest (M) 4"-4781 <br /> APPL1t:ATIN POR W= COWIMtMIGN M ""V Pt tt retail so. Z&A" <br /> THIS PLIe M XMIRS .YRIIR I�llilt! OAT& 1 SWW Date t SOW4 a"� <br /> M (C.wolwta 1a Triplicate) <br /> Applicatiw% is nide to tit* San Jos"Is Lural pealt% District for a pRrraIt CO cvuatr»ct <br /> wad/or inata! i tose work h.ereln descrtbed. This applicatitm 1s arada iw c� limmo with Ran jew"10 <br /> Cwemty 0"tnar.ce No. 1962 and the Rules and Nerdatioms of the tan Jo"Via Laral flralth Distriet. <br /> J+ltt AdDRI'sS/tA?C.A7!QV <br /> 1/8 Crile Wrth of Liberty Rad. 1-1/2 mile East tA%SVS Tum <br /> ����.5�....,.�......�.........�� ,-.�..�...�..-.. �L+- r...�i. <br /> Owa.e t+! Name C'.1 r' i i cit �..�.....�+.+w P�141� <br /> Address 13525 E. LIBEF.TY ROM City T <br /> Contractor's 4a~ Se!t y"In rorno C0. Licewse 1 310378Yt�o}w ,sb9-.1111 <br /> 4 TYPE Of VORK (Uirck): NMIWt <br /> WELL �-7 Dl:I pzN /7 RFIC0MITION Q DESTIM-TION /7 y <br /> PUMP INS,ALLATION ���lA4' 1t8PAIR ��~!illi! RRPUt'iMltiT L-7 <br /> other L� ..,,......�... ----- <br /> nriSTAI1C1: TD 1 : SEPTIC TANK �1f FlIvy <br /> SEWAGE nisposAYIELD CRSS/S lAGt PIOTNF.R <br /> PR()PF.RTY_I.04C - PEI VAn llt> ST t ST 111ii. <br /> 1HTt:!_D1:U USE -- - TYPE OF WELL STRI ION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavatitm <br /> D-Awm tic/pr+vatr _ Drilled Dia. of 1N11 Casing <br /> DomeeCic/puhlJc Driven Gaga of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathectic Prc•, ;t f:,n RotrryT Type of Crout moi` <br /> Disposa! other Other Information <br /> ~MG-Ophys i ('81 y Surface Seal ,t s gilled <br /> PUMP INSTALLATION: Contractor <br /> ---- -- Type of '.'urge <br /> PtTIV 0FPLACC1-11'N1 : / / State W:;rk Dome <br /> PUMP RI'_PAIR., j/ State Work Dom QgILQ JO-Hp TURSVI m4f, TO 40 HP <br /> DESTRVCTin4 of W l.'.: Well Diameter Approximate Depth <br /> Describe Material &nA Procedure <br /> I hereby agree to comply with all laws regu t ous R71WSea oaquZn Loc.l flea t letrict <br /> and the State of �'altfott.,+t pertaining to or regulating well eoustruetion. Within FIIP!'Rliii MTs <br /> after coopl.,tion of my work on a nev well, i will furnirh the San Joaquin local Health District a <br /> WELL DRILLERS R.!OFT tj tho well att#1 notify them before putting ,he wall in use. 7`1w .bare <br /> Information is true to the befit of my knowledge and belief. 1 WILL CALL FOR A GoOM tkSPEC','lON <br /> PRIOR Tt) t:k�i I' A_'::) A FINAL 14VIOnON. J... .. .,v:n Pump t,c <br /> TTTLZ <br /> YAW P E sI <br /> Cult DI!PARTt�NT I/SE I�iLY CMmhrw 95?10 <br /> PHASE 1 d ✓y JATR -2.- ' <br /> AP--pLI:IT! ty ACCEPTED <br /> 11 GROUT I!1SPEC11ON Pi111Sfr 1 I Pi11A1. RCTION <br /> _ p <br /> to!� �Y <br /> .-11 <br /> IiA'r►; H1IRPlt;Tl41i g ATE <br /> TNSP1'CT -. _.��..._-.-..- <br /> e!77 2M <br />