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14 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> 1601 E. Hazelton; '!'�, <br /> #Avd. ,-�Stockt:or,, Calif. <br /> L MEUSE:- <br /> \ <br /> Telephone .(2-0 9)/,4666781 1) <br /> F�l 6 <br /> rAT-ION FOR WELL CONSTRUCTION!`-OR PUMP PERMIT Permit No 7AP7 I - T74 -7 <br /> IS PERMIT -!FRO11;DATEt%1 S SUED -:I)Atd'�Itsue <br /> H XPIRES��,,V�YEAa, <br /> –0cbmple-t6 1A11_Tt1P1i-d-;it0' <br /> z <br /> ad�,L <br /> . I ana��Vjth��,Sa6aquin <br /> Applicatio.iit.ig,-,h-Aqby'-I-made- ,,o the--�San o`aquin1106a1` Health Distt-jct' -�--a�:.peiii a <br /> and/or install the work herein described. Th p e- 'LDi8tr-ict;' <br /> alth <br /> County�.0rdinaticecNo-.r..1862f,-an�dl�th6 rRul-e.r? <br /> 0 �01'ta agSh�T/6�y f,CENS1US,TRACT <br /> JOB ADDRESS/LOCATION tloe S — <br /> w I—law o ;1 <br /> 4F[X o <br /> Owner1 s�Riim& <br /> :L --- --- <br /> Address . 153 pL ---------t . <br /> 5-4 <br /> Contractor's Name License # jcL_� Phone I 7} 2a <br /> TYPE OF WORK (Check) NEW WELL '�/ DEEPEN RECONDITION DESTRUCTION %T <br /> . pul-T INSTALLATION '/ —PUMP REPAIR __ _ 17 <br /> PUMP REPLACEMENT <br /> yo PIT <br /> DISTANCE TO NEAREST,: SEPTIC'TANK, SEWER LINES PRIVY <br /> i I . OTHER <br /> SEWAGEiDISPOSAL,FIELD -CESSROOLOEEPAGE PIT <br /> INTENDED USE <br /> TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> - I <br /> Industrial- L4j,__Cable Tool .', Dia. of Well Excavation <br /> Domestic/private j Drilled <br /> Dia. of Well Casing J� <br /> j . - <br /> Domestic/public I Gaiage of' Casing <br /> a� of. Grout Seal <br /> Irrigation J_–Gr ve -Pac.k. . <br /> l <br /> Other RotaryType of Grout, , <br /> Other <br /> Other Information <br /> ' <br /> PUMP INSTALLATION: Contractor <br /> I <br /> Type. of -pump <br /> PUMP, REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done t V <br /> DESTRUCTION OF WELL. Well Diimeter Approximate 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 the State. of California pertaining to or-regulating well construction.. Within FIFTEEN DAYS <br /> Local after completion of my'wo-kk' 6n a new well, I will furnish the San Joaquin L oc Health District aThe above <br /> WELL DRILLERS REPORT .of the well and notify them before putting the well in use <br /> information is true. to the-b4ist 'of my knowledge and belief. . <br /> TITLE ill olum <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS" <br /> i AL INSPECTION <br /> . PHASE II GROUT INSPECTION PH.AS4­; _FIN <br /> INSPECTION BY PATE INSPECTION BY X-1, - <br /> �) DATE <br /> t <br /> CALL' OR AINSPECTION,.' ------ <br /> GROUT INSPECTION PRIOR,.T0_GROUTING ,AND FINAL <br /> 47/72 lofp-0' <br /> E H 1426 <br />