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SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR OFFICE USE: V111"'.1601 E. Hazel ton�,:Ave."i'Oftockton, Calif.
<br /> Telephone L.,(209)'q'1466-,6781
<br /> APPLICATION FOR WELL CONSTRUCTION OR Pump PERMIT
<br /> Permit No,
<br /> THIS PERMIT EXPIRES -.l.-,�Y-EAR,rIFRO�A,,;DATE-,)ISS-UEDj,,i,',O'I
<br /> —__- �,Z .�-21� --,:: -P,' n 1,J L I
<br /> Applicat�,,oiibi:d..Dhdrq'b�,aidd'e!�.-it-b""bhertatte�-,Jbaquin.cL�o6al) Rd.alth, Diisi-e -3
<br /> and/or install the work herein described. Thfg-f;apblic-atloiivig'�de!,riii-citcotipl! 'mice-'�withhSazi.',�J,6aquin
<br /> j
<br /> County sQrd-,1aaftcecN-o-.T.( -the
<br /> rs, (Rtpow Sad Sbaquin�Ltical%,Health'1-Distr-'ict
<br /> p
<br /> JOB -ADDRESS/LOCATION West on West Ripon Road about 4 'Miles on ,,iciCEN.Stsl-,TRACT.'J-.�
<br /> to TTTF T771
<br /> Owner!d 5N-am8f)1' lo
<br /> Address 827 Walnut Wm
<br /> Ci
<br /> Contractor's Name I. J. Larsen; Pumps , Inc.
<br /> License # 276660, Phone '529 2020
<br /> TYPE-OF-WORK-;�(Che-ck-)-:-+
<br /> New-WELL
<br /> DEE-P-EN--/ /-i;-PECONDI-T-ION DESTRUCTION
<br /> PUMP INSTALLATION '/X/' PUMP REPAIR /7 PUMP, REPLACEMEDfT kA
<br /> 4. .........Other; / 7�
<br /> DISTANCE TO NEAREST.:' ' 'TAXK SEWER LINES ' PIT PRIVY f.
<br /> SEWAGE;,1 DISPOSAL .YIELD CESSPOOL/SEEPAGE PIT:. OTHER
<br /> INTENDED USE '"TYPE OF WELL '
<br /> CONSTRUCTION 'SPECIFICATIONS
<br /> Industrial.. .. -Cable Tool Dia:....of. Well -Excavation
<br /> Dome'stic/private, Drilled. Dia, of Well Casing.
<br /> Domestic/p4blic- Driven.' Gdijge� of.' Ca6
<br /> ing
<br /> 1 Irri ation.- .,.Gravel :Pack Depth:'of. Grout,Seal
<br /> Other
<br /> Rotary Type of Grout
<br /> 'Other ' Othe-:r' Inf 6rmatibn
<br /> PUMP INSTALLATION;; -' C6hfra:ct6r
<br /> 6,Type
<br /> ; Pump mp I �H.F. subm. H.P.
<br /> ;State Work Done
<br /> PUMP; REPLACEMENT;.:
<br /> PUMP RE'P' AIR.- State Work Done
<br /> ,PESTRUCTION
<br /> App-r-.oximate-Depth
<br /> Describe Material and Procedure
<br /> I hereby agree to- comply .with. all laws -and regulations of the San Joaquin Local Health .District
<br /> and lthe-St4te, of, California pertaining to or regulating w' eli construction. '; Within FIFTEEN DAYS
<br /> aft'dr completiodof; my' 'w- okk on a new well, I will furnish the San Joaquin Local' He' alt:h District a
<br /> WELZ DRILLERS, REPORT- of -the well and notify them before putting the well in use. The.-above
<br /> info`rmation i'
<br /> s true ito: the best of 'my :knowledge and b4ilief.
<br /> SIGNED
<br /> �TITLE
<br /> Wvw PLOT PLAN ON REVERSE SIDE)
<br /> .FOR DEPARTMENT Us "ONLY
<br /> PHAS,'E I
<br /> '� 'BY _Z7
<br /> APPIjICATION ACCEPTED :DATE
<br /> ADDITIONAL COMMENTS
<br /> PHASE II GROUT INSPECTION RASE I/-FINAL INSPECTION 7
<br /> INSPECTION BY DATE INSPECTION BY
<br /> PATE 2
<br /> TO GROUTING AND FINAL INSPECTION.
<br /> E H 1426 4172. _ _ 1M
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