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ALIH 1)[STRICT <br /> SAN l0A()1.AN LOCAL 11 ,ELoll, Calif. <br /> F U,ICI.: S.E: 1.601 1 AVe - <br /> rc l.epl'one: (209) 466--678t <br /> FERMLr Permit <br /> CONSTRUC'FlON OR rUi`V <br /> -31 API'Lf.(-.A!fl()N 3l <br /> . I YEAR pRoM DATE ISSUED Date Iss"Od —f- <br /> 1:11S PERMIT EXPIRES <br /> -'T�J:lcate) -%let <br /> L),,� <br /> (C jeLe In Tr District fora permit, to construct <br /> to the San .1ozitl1lin Local health Distr ompliance with San j, 1n <br /> cation is hereby made ppilcation i.s made in c <br /> r install the work herein described. Tlij.s a the San Joaquin Local Health District <br /> y Ordinance No. 11362 and the Rules and Regulations of CEj4sjjS TRACT <br /> YZI <br /> �7 n Phone <br />-Is Name <br /> city <br /> I L n s e i'lione <br /> ractor's Name <br /> TION <br /> RI.-CUNDIT10N DESTRUC <br /> WE'Ll, -_PUMP RE <br /> OF WORK (Check): NEW ()N pUMr jj_:pA1R PLACEMENT <br /> pUmp INSTALL0 <br /> OLher <br /> ----PIT PRIVY <br /> S <br /> ............. .. _�54ER LINE OTHER <br /> — SEPTIC TANK /SEEPAGE PIT <br /> L"J"I"ICE' 1110 NEAREST: cl,';��100L <br /> - <br /> OSEWAGE DIS?67ALFll:LD — PUBIC TME <br /> TTIC WELT.PROPERTY ,INF. 11RIVA-LE t,FI LCONSTRUCTiONSPECIFICATION <br /> S <br /> on <br /> D USE jypE OF WELT. �xavatjon LZ <br /> INTERDE Dia. of l4e <br /> Cable rool <br /> Industrial Dia, of Well. Casing <br /> Ur L1 led <br /> Domestic/private Gauje of Casting In <br /> Gri%vo 1 P-'Ick �e,'�;Affttl��5 <br /> Domestic/public Driven Depth Of Grout <br /> Irrigation rype of Grout <br /> Cathodic Protection ItOLAI-V other other Information <br /> Disposal Surface Seal InstalledB <br /> Geophysical <br /> tor H.P. <br />-U, !NSTALLATION: Contrac <br /> Typo of PUml) <br /> MP Dono <br /> State <br /> REPLACEMENT: <br /> State Work Dolle <br /> Approximate Depth <br /> tiTRUCTION OF WELL: Well i)Lametere <br /> Describe Material171ce'lu� <br /> - - -f— lealth HS rict <br /> 'T-T U <br /> f 11 ,an joaquill Loce <br /> 1-3 t fu 11.4 Within FIFTEEN DAYS <br /> lioreby agree to comply <br /> with a1 ur rv,.,jl.ating well constructi.On I ll.alth Di.striet a <br /> California I'C"'U" lie San Joaquin LOca --je <br /> n,I the State of '�w Well., I w1il furnish L well in use. The abt <br /> fter completion Of my work on it n them before putting the <br /> 1:1,1, DRILLERS REPORT of UIL Wul I- 'llid noLify I ge and belief- I WILL CALL FOR A GROUT <br /> I'I I IN. <br /> 1,1y knowledge'L!k <br /> _1'U GROUTiNC AND A_fINAI" <br /> ti(ormaLion is true to 1:jio best <br /> ,A1ON SI <br /> DF <br /> l� <br /> ljqj,- ONLY. <br /> C) I)ATE <br /> ACCEPTED "y FINAL IliSPE <br /> COMMI'N' S' PHASJ, TT <br /> 1 ,T_ <br /> IN AL T, I." - -T I ON ll� <br /> I!)S I <br />