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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel ton'-':Ave_.- ).9Eockton, Calif. <br /> Telephone 05")t�e46G6 7 81 <br /> APPLICATION FOR SELL CON8TRUCTIONAOR PUMP PERMIT Permit No. <br /> THIS PERMIT.rEXPIkES,,�ll.YEAR, "PROI�IcDATEiSS-UEDI,;.-,L}' <br /> (Complete <br /> y1­v4 Z <br /> Applicatiotibi, -,hdreby,,,made,jrto bh-e0Sa`n4.jJ6aquin_'1o6aj ljaaljh 0 <br /> and/or install the work herein described. Thig...,apbjj cj at ton v ig-,made lifi.cy <br /> IC01hpl!1&tice- with hSdrivJ6aquin <br /> County:�Qrdimafice oNosr,,18 62 tr-arid'7thi efRulTieg baftd PDRejuldti'Ofig f6 f6t1fe,Sa-fi'Uoaqtiih­Lo,dal"=H4alth°�.Dist-rfl ct <br /> Ej_tdlin�oq 7:?,F1jo yvn i(_,5 <br /> q <br /> JOB ADDRESS/LOCATION N." W. corner Cirrolton _ <br /> Lone Tree •-'f-,10EN.sf.jS,,TRkC_TjC'1 <br /> 7a <br /> ,Owner!sl�,,Nim-01 avI&G,.t �� EUI:QTV_4f,� C-e, <br /> e�_ 8.38 <br /> ad <br /> Address 19325 E. Lone Tree Ro <br /> �City.A��alon, CA <br /> Lice, <br /> Contractor's Name a, nse <br /> License # <br /> _h!*.2766 d1hone 5 2 9-2020; <br /> TYPE OF WORK (Check) :'--NEW WELL-'-/-/ / /7RECONDITION_/_7__bhSiffURTIO <br /> N <br /> - PUMP INSTAL <br /> LATION '/ PUMP REPAIR f / PUMP REPLACEMENT <br /> /x <br /> ... . , .Other.: <br /> r q <br /> DISTANCE TO NEARES7:, -SEPTIC <br /> SEWER LINES PIT PRIVY <br /> ...... SEWAGE;,DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT . OTHER, <br /> INTENDED"USE 'TYPE' OF WELL ' <br /> CONSTRUCTIONSPECIFICATIONSIndustrial. . Cable .Tool Dia. .of f 'Well Excavation <br /> D 'sti'c/ <br /> ome private: Drilled 0 Dia. of Weli Casing , <br /> Domastic/p4blid riven, Gaugd'-of Ca631 n g <br /> Irrigation.. . .. 'L Gravel ;Pack Dep' th:,eof Grout.Seal <br /> Other <br /> it Rotary - Type of GroutC� <br /> -Other Otherlnfokm"a <br /> ion ; <br /> PUMP INSTALLATION: Cohtractor <br /> Type of Pump H <br /> 7 <br /> PUMP, REPLACEMENT: State VYork Done Ins <br /> PUMP n <br /> PUMP REPAIR: State <br /> Work D6ne.--- <br /> _J <br /> ­;7We1l­Diaiife- gi ......... ..... <br /> oximate <br /> -1 and� Procedure <br /> : Describe .Maieria <br /> I hd'reby agree to comply <br /> with -all laws and regulations of the San .Jodquin Local Health Districli <br /> and the State: of: <br /> California pertaining to or regulating well construction. Wi:thih FIFTEEN DAYS <br /> after completion of7my'woik 6i-i a new well, I will furnish the San Joaquin Local Health District <br /> WEU DRILLERS, REPORT of; the. belland notify them before putting the well in use. iThe-above <br /> information is tothe s my <br /> true: t �of , 'knowledge and beli6f. ; <br /> . <br /> SIGNEDV4 <br /> :TITLE . 1P/1/75 <br /> it <br /> (DRAW PLOT PLAN ON REVERSE SIDE). <br /> 'OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z55�,�, <br /> ADD*IOkAL- COMMEkS�. DATE <br /> 7 <br /> PHASE I-I GROtTZINSPECTION- <br /> PHHASE jjI/kINAL -fNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> dAL <br /> L_TQ1k.,:4_ PRQVL;NSP`EC'TIbN PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426~.._- <br /> 426 <br /> 4/72 'IM <br />