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-: SAN JUAQuItt LOCAL• HEALTH DISTRIC <br /> FO' OFFICE USE: 401 E. hazelton Ave. . Stocktnn, Cal Lf. <br /> Ielephone: (209) 466-6781 <br /> .•T"' :(-,'•TION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nu. 4d <br /> ?+IIS PERMIT EXPIRES_ 1 YEAR FROM DATE ISSUED Date IRqued <br /> (Complete In Triplicate) <br /> tp,licetion iR hereby to the Snn Jonquin Local 11enlrh District for n permir to construct <br /> rind/or install the wort, '•ter-tn 'encribed. This application is made in compliance with San Je.-,uin <br /> County Ordinance No. V-'.' -n- the Rules and Regulatio" of the San Joaquin Local stealth District. <br /> .TOB ADDRESS/LOCATION �l � /,:� � i CENSUS T!'LAC': <br /> f�.rner s Name ( - s ��-- ---��c !i='i! t Phone - <br /> Address -�._._ /,: c� City -- <br /> Cnntrnctor'a NnTr+ License d?,',•',�; PhL•nr. d <br /> 1 ��_. - /'R.-et/s'Yvn.-T..•_•.141�I.O�Yh[}fD•Y,T vwsar_.041/�•'A4�IT'.I��... ��• <br /> TYPE CF WORK (Check) : ". / J DFKPLN / 7 RECONDITION_ /-7 DESTRUCTION /- <br /> T � I CF.f -'NT / l <br /> ' .41.r.e1.ION /_., PUMP REPAIR � PUMP RrPLA <br /> DISTANCE TO NF.AkEST: $EWER LINES T FRIVY���_ -- <br /> ' ':POSAL FIELD CESSPOOL/SBF.FAGr PITOTHER <br /> '..INF: - PRIVATE D04FSTIL' PI1n1 TC I1tlMF.STIC WF.L1.� _ 1 <br /> 1NTENDED USE : rrl: OF WELL CONSTRUCTION tFF:CIFICATIONS <br /> --_.- , <br /> Industrial _ ,L Cable Tool Dia. of Well Excavation .� <br />` Domestic/private' _ Drilled Din. of hell Casing _ At <br /> Domestic/public _ Driven Gnuge of Caning <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protecti—, Rotary 1 •oe of Grout _ <br /> Disposal Other OLner Information <br /> -Geophysical Surface Seel Installed BY: r, <br /> t <br /> HIMP INSTALLA.I011: Cotitrnctor C ,(. a ►< 4�. Is 412 <br /> ��+ • <br /> -- Tvpe' of Pump H.P. <br /> i.U-P REPLACEMENT: / ; 'tater Work Done <br /> t ;T14P REPAIR: 1 °I n t e• Work Done <br /> 1 -- <br /> f-!;TRUCTION OF. WFLL: Approximate Depth <br /> r1t•e K.eterial and Procedure <br /> I hereby agree to co"<ril•,• -:et', ,111 lawn and r�-Aulatinna of the San Joaquin Local Henith District <br /> and the State of Crelit rtt: :• rtiining to or regenlnting well construction. Within FIFTEEN DAYS <br /> .After eovnletion of w••,r� • n a new well, I will furuinh the Snn Joaquin Local Health District is <br /> 14ELL DRILLERS REPOR: -f it -, vol l and notify them before putting the well in une. The above <br /> information is tree, ! the t1•••t of my knowledge and belief. I WILL CALL FOR A GROUT !NSPF.CTION <br /> PRIOR TO GROLITIN' " '' 1•..1', :" P F.CTION. '-- <br /> SIGNED _ _ TITLE <br /> — DRAW PLOT' PLN ON RF.VFRSP, SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Al'I'LICATION ACCF..P"'') s+ �� DATE `I' -� ' <br /> AT)DITIONAI. COMMP:T S, _r"►'� <br /> PFiA*_ :I _".>PECTION PRASE III�FINAL INSPECT�O�INSPECT] <br /> INSPECTION BY� j'Ai INSPECTION BY DATE <br /> DATE �� + <br /> E H 1426 F.e'V• A U75 2M <br /> 4 <br /> e <br />