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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel.ton�VAve.'�"618;Eocktor,,' Calif. <br /> Telephofie.:".�..--(249)x.44666781 <br /> APPLICATION FOR WELL CONS�RUCTIUNAOP, pump PERMIT Permit No. ;7t'l-j.5-2)o <br /> THIS PERMIT.r)EXP TRES I sYEAR-,`VROM,,'-'DATE:)ISSUED I,f)-i <br /> Applicat*oiibis.,-,hi:reby-cmade-st-o tbe.0SanfTJbaquin1.- :o&-1 Ralth DtsEreia forit��t' ,_,coii§ vuc�f <br /> a " <br /> e ti r% tmi 0 t <br /> and/or install the work herein described.' Thi 9 rnappi ic fttkawrl;;�'_made f iii,_,t comp lilwi ce,,wi th=,Sati%'Jd aquin <br /> County:20rdinaacec,No7ql862i;randyth67.,Rtite'SE,aiftdRogul�t-i,otisD6f,z'-th"e,San",'J'oa'q- ­ Lo,�al,`H_uj -n-- ealth:[Dittiict.- <br /> cifdk�3poq uofljn <br /> JOB ADDRESS/LOCATION 19325_,E.- Lone Tree Road Lone Tree su'iCENSUS!;TRAGTTO <br /> --2 <br /> Z-858 t -158kfino-1 <br /> Owner!v�Nam&)j' at) 0 <br /> Address., Escalon,_CA.-- City <br /> Canirtictor's License <br /> Contractor's Name <br /> License # �. �nPhohe 529-2020 <br />-TYPE OF WORK-(Check <br /> )-.—NEW WEL <br /> - PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> A-T <br /> 'Other; / . I <br /> DISTANCE TO NEAREST:' '-SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGE: DISPOSAL -FIELD . CESSPOOL/SEEPAGE PIT, OTHER <br /> INTENDED 'USE 'TYPE' OF WELL' CONSTRUCTION'SPECIFICATIONS <br /> Industrial. .. ..' <br /> Cable .ToolDia. of Well Excavation <br /> Domestic/privates 7 Drilled <br /> Dia. of Well Casing <br /> Dbmestic/pbblic,- Driven ' Gaiige' of Casin' <br /> 9 <br /> Irrigation ,Gravel Pack . Depth! o Grout, Seal <br /> Other Rotary <br /> Type of Grout <br /> Other Other' Inf&rmation: <br /> PUMP INSTALLATION; t6iitri;-ictor <br /> Type of, Pump <br /> H..P. <br /> PUMP REPLACEMENT.: X/ 'gtai6 T�ork Done Full old pump install 2 h.p. subm <br /> PUMP <br /> REPAIR: State Work Done <br />.PE-S-T-RUC-T-1-ON-OF-..,WE,L-L-:-.—,-We-1-1-Di-a-me:t�irte: Dept <br /> Describe Material and Procedure <br />'-I hereby agree to comply ,with-all laws and regulations of the San Joaquin Local Health District <br /> and1the State; of' California p'ertain'ing to or regulating well construction. Within. FIFTEEN DAY..S' <br /> after completion of; my'wo'kk on 'a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in .use. The .above '' <br /> information is true to, thq be:st'of my .knowledge and belief.." <br /> SIGNED rte ......... TITLE 4/25/76 <br /> (DRAW P PLAN ON REVERSE SIDE) <br /> MENT USE ONLY <br /> PHA9E I 4,�EPART <br /> ?T <br /> APPLICATIONS <br /> A­CCEPTE VA DATE J�� ✓T ! <br /> ADDITIONAL C014MNTS <br /> PHASE 11 GROUT INSPECTION- HA <br /> P SDLIIn-INA1- INSPECTIOV <br /> INSPECTION BY DATE INSPECTION BY DATECALL' FOR A GROUT _7 <br /> INSPECTION PRIOR TO GROUTING AND FINAL IN ON,. <br /> E H 1426 4/72 1M <br />