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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r6� <br /> FOR OFFICE USE: 3-1601 E. Haz..eltonijAviB." -SEock'�:on, Calif. <br /> Telephone:"'',,-(209)104666 6781.APPLICATION FOR W.ELL-..CONST.RUCT.IDNAOR PUMP PERMIT Permit No. <br /> THIS IS' PERMIT ,E I R E S-,,11 V E k R-d F R0E I c;D A T BE 19,S-U EA x oD a C.e 91,99u,d! 7 y! <br /> l <br /> 6mo I On- <br /> e fsvI <br /> Applicati.Wbil:;hdreb3 -madel'ito' th:eoganczj6aqui=.~ho6all Hialth <br /> and/or install the work herein described.. <br /> County Ardlnaiice <br /> )V <br /> ,)TV -v7,Wy ,y*) C <br /> JOB ADDRESS/LOCATION _ <br /> 1,o <br /> Owner'a <br /> Ankm! <br /> Address Is-hp <br /> Contractor's Name &-2Ae,L<. A,A-1 P -S License # 2bC)7!y Phone ft.4 - <br /> TYPE OF WORK (Check) : NEW WELL /W DEEPEN /-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTAL ATION PUMP REPAIR PUMP REPLACEMENT -7 <br /> DISTANCE TO NEAREST: -SEPTIC''TANK , ",-- SEWER LINES PIT PRIVY <br /> SEWAGEDISPO$AL ,FIELD ­ CESSPOOL/SEEPAGE PIT . OTHER <br /> INTENDEDUSE -TYPE OF WELL ' CONSTRUCTION ',SPECIFICATIONS <br /> /' Industrial' Cable Tool. DiA. of Well Excavation <br /> K! Domesti.c/private. Drilled Dia. of Well Casing <br /> Domestic/pi b11L 'Driven ' R <br /> Gauge' o£' Casing <br /> IrrigatioK J ...Gravel 'Pack Depth, of; Grout ;Seal <br /> E--A&E� ALI-_ <br /> Other <br /> Rotary Type of Grout C <br /> Other , Other Information <br /> 41­ <br /> PUMP INSTALLATION: ' Cohtr4dtor <br /> .Type f-P H.P., <br /> Pump <br /> L <br /> PUPUMPREPLACEMENT:*. �9—ta tW <br /> e-, ,o�k Do�ne % <br /> PUMP REPAIR: State-Work Done <br /> A <br /> ,PESTRUCTION OF WELL: Well Diameter Approximato- Depth <br /> De8cribe Material :and, Procedure <br /> I hereby agree to strict " <br /> comply with all laws. and regulations of the San Joaquin Local Health Di <br /> and ithe State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> afte',r completion' ofr'my'wokk on i new well, I will furnish the San Joa.quin Local Health bistridi a <br /> WELI DRILLERS REPORT of the well and notify them before putting the well in use. The .above <br /> infQrmatigg ip,.true7to':the b6st .of ,mykno'wledge and belief. . <br /> SIGNS <br /> TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR. DEARTMENT USE ONLY <br /> PHASE I <br /> L <br /> APPLICATION ACCEPTED" BY <br /> DATEl- <br /> ADDITIONAL COMMENTS;: <br /> PHASE II GROUT INSPECTIQV PHASE FlbTAL- INSPECTION/ <br /> INSPECTIONBY <br /> PATE INSPECTION BY DATE <br /> L <br /> CALL FOR A GROUT! INSPEdTION, PRIa`TQ GROUTING AND FINAL INSPECT' <br /> E H 1426 4/72 1H <br />