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<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR OFFICE USE: 1601 E. HazeltonVAve.,,S' ocktorz, Calif.
<br /> Telephone:,,.. (209), 4W,6781
<br /> APPLICATION FOR WELL CONStRUCTIONAOR PUMP PERMIT Permit No.
<br /> ZZY/0
<br /> THIS PERMIT oEXP I RES�z I 1VEARd FROM,,DATE,-,-I S SUED b
<br /> 0mialdt"e
<br /> Applicati-odbi:§-)hdre,by,smadff7to bhetZa.-nqJoaquin1Le&a1 ndalth
<br /> and/or install the work herein described. Thi!S6ap{lli-.catibnjig,-)madeAifi-,-icompl:i,6:fice�'vit.hf:San`,,Jdaquin
<br /> 'County�Qrdina-nceoNo7ril862iria-tid�,thdrRule6i-,and r;-R6gulti-tk6ns_-.6f-oth e ',;District.
<br /> JOB ADDRESS/LOCATION 30947tLee Road,'. Escalon -fXCENSUS,1.TRACT1,,
<br /> 7§a o_s q 1,4 1 n o'-h T-> �:T j.-e q ri-j q- .9 i
<br /> Owner!r; N Ek§ham.-,, i A.ti-v ip !_22 11C 3
<br /> m� 0 iw, 'I u
<br /> 9 .7
<br />, Address same City..
<br /> Contractor's Name I. J. Larsen -Pumps, Inc. License 9Qn1ractor'sE'Mfte ' 529-2020
<br /> -tft-276660
<br /> -TYPE 01�'WORK (Check)-. MEW-WELL/7 DEEPEN,'/—/ RECONDITION DESTRUCTION /_7
<br /> "- ' PUMP -INSTALLATION- 'PUIT-RFPAIR'-/;-�PUMP-RE151:,krEME
<br /> NT—/
<br /> Other../ /
<br /> 0
<br /> DISTANCE TO NEAREST, 8EPTICTAXK ' ' SEWER LINES PIT PRIVY '
<br /> SEWAGE, D15POSAL FIELD . CESSPOOL/SEEPAGE PIT ;.. OTHER
<br /> ► "
<br /> INTENDED USETYPE OF WELL'. CONSTRUCTIO N'SPECIFICATIONS
<br /> Industrial-
<br /> _. J., Cable .Tool Dia. .of,Well .Excavation
<br /> Domestic/private -illed
<br /> I Dx Dia. of Well Casing
<br /> \
<br /> Domestic/public Driven GaUg& 6f' Casing
<br /> .il :'Irrigatiod.Pt,.,,� :A,- Gravel Pack Depth-, of Grout Seal
<br /> T_
<br /> Other,, Rotary Type,;'of Grout
<br /> 'Other- Other; Information'
<br /> PUMP. INSTALLATION' Co'nfiAc'tor
<br /> -7 Type of:,Pximp' H.P.
<br /> PUMP REPLACEMENT: State Work Done
<br /> Removed Sbasta pu aCptj -.ri +.h Myer-q 1
<br /> PUMP REPAIR: State Work Done
<br /> f
<br />.DESTRUCTION OF WELL,:---Well Diameter, p_Approximate Dep_th. _-- _
<br /> _. �__ ;
<br /> Describe Material 'and :.Procedure
<br /> 4
<br /> I hereby agree to comply with.-all laws and regulations of the San Joaquin Local Health District
<br /> and 'the State of California pertaining to or regulating well construction. - Within FIFTEEN DAYS
<br /> arter completion 6fmy'work-or r i,A,;,'n ew w&1-1, Iw-ill—furnish-the-San Joaquin Local Health Distric,t a
<br /> WELL DRILLERS REPORT of the well and notify them before putting the well in t;sia. The above
<br /> information is true, to the b6st .oVmy :knowledge and belief. ,
<br /> SIGNED TITLE '
<br /> Inc -
<br /> (DRAW PLT LAN ON REVERSE SID—E)
<br /> FOR DEPetRTMENT USE ONLY
<br /> PHASE I
<br /> APPLICATION ACCEPTED BY
<br /> 574 j- DATE
<br /> ADDITIONAL COMMENTS:
<br /> PHASE II GROUT INSPECTION
<br /> PHAII ,
<br /> FINAL JI �FINAL INSPECTION
<br /> DATE INSPECTION
<br /> INSPECTION BY BY DATE
<br /> -
<br /> CALL FOR A GROUT! INSPECTION GROUTING PRIOR TO GR 'TING AND FINAL INSPECTION.
<br /> E H-i42-6 4/72 1M
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