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SAN JOAQUIN LOCAL :HEALTH ,DISTRICT
<br /> FORIOFFICE USE: /1601 E. Hazertoti:,,-Avd.1, '.Std6kton, Calif.
<br /> Telephone: :`,-A209} 46.6.- :,81.'6.7
<br /> FOR AU"'CONSTkUCTION OR PUMP PERMIT Permit No. -5- 379
<br /> lrt/
<br /> ' 4v I is
<br /> THIS, PERMIT-XXPIRES. 1�,`YEAR-IXROM,ZATE-�ISSUED,,-4,
<br /> (Complete.in {Tr;,iplicate).)
<br /> Application is hereby made to-the Sano joaquin.,L.ocali.,He.a.ith-)�Dia-trict"-'.,for a:ipirmit-,,tw.con- struct
<br /> :and/or. install ,the york. herein described.� 4 ,�
<br /> 8,made,Ancompliancd i4ith`Sdn Joaquin
<br /> ,.�,P.This 'application
<br /> County':6,rdina--n-ce No.1-1 ,an e.-Ru. e6-,andRe ulatiQns 1,ofikthe San-,Joaquin;Local I HeAlih"Dist i,ct.
<br /> 14 1 N2;, 3
<br /> —W_A_
<br /> JOB ADDRESS/LOCATION �CENSUS,`TRACT i:1.,i Al
<br /> Owner'i"Name Phone
<br /> Address -City
<br /> I JL.0 ,4g
<br /> Contracto�r
<br /> .s Name- 1�
<br /> ,
<br /> —4 7
<br /> 7CYI'E or WORK (Check): NEW WELL DEEPEN-
<br /> /7 RECONDITION l s DESTRUCTION IT7
<br /> PUDW ;INST&!AtION' /U47-eb-M REPAIR -7. P"UMP, REPLACEMENT. V-7.
<br /> REPAIR /
<br /> .Othei
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES PIT PRIVY
<br /> S9WA09 IbIISPO_SALFlt.tD CESSPOOL"/SEEPAGE PIT: OTHER,
<br /> PROPERTY .-LINE DOME PRIVATE STi C"WELL' PUBLIC aDOMESTIC WELL
<br /> TYPE OF WELL;
<br /> 1NTENDED USE. t. k CONSTRUCTION�SPECIFICATIONS
<br /> JI .A.
<br /> 4--table Tool Dia. �of Well EXcavat'
<br /> lndust�rial ion ; Is;
<br /> �Omeat ic/p_ ri*ate Drilled, Dia. of We
<br /> "1I-11 Casin
<br /> .
<br /> Domestic/public- 4 ven �6g4��Of Caii
<br /> on Depth of
<br /> 4 Vim. ;Irrigation Gravel" Grout; Seal
<br /> 9 Cathodic. Protection ..... ii Rotary` Type of
<br /> Grout
<br /> 1 1 Disposal j I Other Other Infamation
<br /> Surface Seal Installed By:
<br /> deophysical jFe_1
<br /> Pump INSTALLATION: ` 6ntiacfor
<br /> Type �of Pump i H.P
<br /> :
<br /> PUMP REPLACEMENT: State Work
<br /> 4
<br /> ' i -
<br /> PUMP-�,.-REPAiR; : /7--stAtewo rk�
<br /> JDES,TRUCTION OF WELL: W411 Diameter Apptoxiinate Depth
<br /> Desceibe':!Xaterial';and Procedur6' " !
<br /> I heie" by agree to comply with all laws and regulations of the San ',Jodquin Local Health District
<br /> and', the State of Cadif,orgia .pertaining to -or -re I gUlatiiig well-construction. 7'WithiiiVIFT]tEN D08
<br /> after completio of. work c
<br /> ft jaj.. on d new well I "will, the,San :Joaquin LQ' alL Health bist'ric.
<br /> WELL, D- RILLERS. REPORT of the well and notify before putting- tfie . ' 11 in use... 'The above
<br /> we
<br /> mat-ion is true -to'. the. "knowledge' -b' 1W
<br /> in formation best' 'and eli6f......I'L !?Ok-'A:'GROUT INSPECTION
<br /> PRIOR TOG
<br /> ROU A FIN&Th INSPECTION.- .
<br /> SIGNED"
<br /> TITLE
<br /> .. ..... (DRAW-PLOT PLAN ONREVERSE `SIDE) I -
<br /> ..4FOR -DEPARTMENT -USE,�ONLY,
<br /> PHASE I
<br /> A
<br /> DATE
<br /> APPLICATION -ACCEPTED BY
<br /> ADDITIONAL COMMENTS:
<br /> J
<br /> ',PHASE ',ITGROUT INSPECTIOW PHASE III FINAL INSPECTI014ji��/�_
<br /> INSPECTION BY DATE
<br /> W 114)1. i
<br /> INSPECTION By—ky, DATE
<br /> E H 1426 Rev. .1-74 1-74 2M
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