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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltonl�Ave.'3(-gbockton, Calif. <br /> Telephone:('-,(209')�,-,'466: 6781 <br /> APPLICATION FOR WELL "CONSTRU'CT1WOR PUMP PERMIT Permit No. 7V=-2,t11.4) <br /> 1,6 a 167 <br /> THIS <br /> ou <br /> Applicat�oxtbi%l.okereb.y,imade:,,itG t-heoSanqJ6aq.utn!Uodab Adalth- <br /> and/or install the work herein described. <br /> JOB SS/LOCATION a Al. ISL "1 0 <br /> I ICCHNS-U fTR-A�GT I <br /> %1-nvqo 3 ygqlnlnf-bs 'SO 91il flo it 'C c"I"sw 's!7jific% <br /> -Nima 0 tij 1* <br /> ""-I ;'vil i <br /> Owner'g,; Z4 io 170 on <br /> Address 731 ? OU I A I—?-C' ja A,d- City <br /> Contractor's NameU' 7,90Ac e ScSpm #2 License 40 <br /> 74 <br /> q Phone4j0L- J)b <br /> TYPE OF WORK ,(Check) : NEW WELL y&.—DEt-P RECONDITION /7 DESTRUCTION :/7 <br /> ,'PUMP INSTALLATION )M7 PUMP -REPAIR '/' / PUMP 'REPLACEMENT 117 <br /> - <br /> Other! / 7, <br /> DISTANCE TO NEAREST: SEPTIC:TANK V13 <br /> SEWER LINES PIT PRIVY ' <br /> -1SEWAGE';DI$POSAL ,FIELD , ---CE SSP.O.OL[SEEPAGE PIT OTHER <br /> 0, <br /> INTENDED'USE -TYPE OF WELL- CONSTRUCTION 'SPECIFICATIONS <br /> Industrial' Cable Tool Dia.. ,of Well.Excavation <br /> Domestic/private Drilled ' Dia. of Well Casing 'a <br /> -Domestic/public ` Driven G96g6-of7' CAsing <br /> Irri <br /> Otiod'.. . .Gravel PackF Deip' tW of Grou t Seal <br /> Other Rotary Type-of Grout C.E-A/ E& <br /> 'Other Other: Information <br /> PUMP INSTALLATION: ` Contrdctor <br /> TyPe of PumpHP. , <br /> PUMP REPLACEMENT'o —S-Ca—tE-146;rk Done"' <br /> 41 <br /> PUDff� REPAIR: State Work: Done <br /> ,PESTRUCTION OF WELL: Well Diameter Approximate Depth. A <br /> I ;Describe Material and Procddtfr-e <br /> I hereby agree to comply•with al:1 laws and regulations of the San Joaquin Local Health District : <br /> and 1the Stite; of. Califo'rnia pertaining to or regulating well construction. : Within FIFTEEN DAYS <br /> aftO co 'Imy'woik on a new vielll,* I wild the San Joaquin Local Healt <br /> completion` h District' a <br /> WELL DRILLERS REPORT-,.of-the..we.11",-an!d .notify them before putting the well in use. The .above <br /> inf drmatio-h is tiueito: the best of My knowledge: and belief. :� <br /> SIGNED <br /> A,d:A 0 <br /> (DRAW PLOT PLAN ON REVERSE 4IbIE <br /> FOR DEPARTMENT USE ONLY <br /> PHAS)E I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASA2X GROINSPECTIO 7 PHASEINSPECTION <br /> INSPECTION,BY DATE -5--6 Z. INSPECTION BY E z?-2.L11 <br /> i <br /> CALL' FOR A CROUTi4INN7�STPIE�'TION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />