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SAN JOAQUIN IaOCALTIMALTH DISTRICT
<br /> F'OR!OFFICE USE: 1601 E. Hazel;t0A13AvdT,WSf6`r'.'kton, Calif.
<br /> Telephone i 1(209) 4 '6,;617,81
<br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No.Tom.. All
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<br /> THISY PE, kT'�XPIRF Li,Q1"4p�DATE,I1SSi.ED
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<br /> Appiica ion is hereby made toi the San Joag14:-A l oca1_jFl"-7th;. 1i� :t is .air gar ps i ti o=tom a nst
<br /> and/or i.knstaa p ° e des8 b�d.� e� s#app 3 a o = flesh us�campld is iriw,-�Sh �.lnaq 'n
<br /> County Ord dance No• �8 aq ' the Rule . d R gu at ans, of tae;.S z► Joaqut Local HeaJl h'vDis- ict. �
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<br /> (?wraer s Name r , -s�,-�pc�� Phone`s f L'- 1-3 cp.
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<br /> Coi�trAFtb7r'. •Name, .. cinse #I` ,,phone{n1-4-T3
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<br /> TYKE.,OF. raoRK. .( heq ).:, ..-NJZW ,idELL / .DEEPEN../_ RECONDIT1bN /�� DESTRUCTIDW17
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<br /> PUMP. INSTALLA QN % PUHP REPAf R PL#MP .REPLQCEMEN
<br /> DISTANCE TO ,NEAREST: ! SEPTIC K Sr PIT PRIVY, {
<br /> TAN SEWER LIME
<br /> SEfAG ` DiSPbSAL FIELD; , CESSPQOL/SISEPAGE . IT OTHER
<br /> 9
<br /> .......�....,.. ;..,, .....,;,,.....i.P`RPERTY1LINE PRIVA DOMEST C.,.WELI .�::... CD
<br /> Ukia OMESTIC WE L
<br /> a !INTENDED !USE i t TYPE OF WELL i CONST_ RUC ION SP a
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<br /> _;Industridl s i Cab o� 1 tIo
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<br /> ,..Dor p.,; Drilledo Dia hof �1eZ] ,Casing Y. .
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<br /> ,Dot sfic ubli } > 1g----._----J
<br /> /p ci 'Driven G�ugd of Casins
<br /> a •Irri'gati.oii ` ' ,; ' `' ;Grave], Palk LLDepth of Gout Seal f s
<br /> .., Cathodi.c. roiectio .4.. sRoCary -Typef of"sGraut:-�.....:... . . .:... ,. ..s �. ... 1..,,._...
<br /> E„ Disposal ; ; Other Other In£ormat on; i i i
<br /> 6Ceophyeic�ei] �; —` 'i surface Sea Instilled
<br /> PUMP iNSTALLATION:' i Gontractor ! �� — z x
<br /> T pe'i of ;Pump o fir--�- a s ` .P.�/on i 3
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<br /> PUMP REPLACEMENT: / / 1 State Work„Done, " ! '. i .... x..
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<br /> REPAIR. ,,.. ; ;. �..../ State4�Work,none
<br /> ESTItUCTION OF WRLL We1l{Diameter P i Approxfmate Depth
<br /> hr.... . ..,_ �. ..Dscrib ...Msterial�-and ~PtocduYe
<br /> hereby lagriBe to comply with all ;laws and regulations of the .San, Jo#quip Isocal Health District
<br /> ana..tt e•'.5•ta-te o€'•.Cali•forAia Penta nine •to or 'regulat, ing reljl"coristriictioii�' W thin I Ad`HAY$
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<br /> - er 'ca�dgletion of work ion ;a„r�ew sell, I„Will, furnish..the..5an_Joaquin..Local Health �D�is* icir
<br /> WE L iSRI1iLER5 R PO
<br /> AT of the .welil, and (notify; them tefdre punting..the..wel id use.. S The above i
<br /> in or-matron is true to the,bes&,oL my� kngwledSe••.and tiali�£,f I WIYrI; Clll;� F01� A GRQUT 4 INSPECTION
<br /> PRIR TQ GROU NG AND 'A INALi INSP CTiON: ' a.. <.,>.....
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<br /> SIOUP E TITLE.
<br /> .... ........... !` RAW PLOT:PLAN° ON REVERSES"SI1�E
<br /> . .. ... ,.�, .a. .. i ,....r.. `.FOR..DPPAItTMENT U5E4 ONLY...
<br /> PHASE }I
<br /> APPLIGATIQN"i�GCEPTED
<br /> AD;ITWN d ,.CO1"II�It<:NTS:
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<br /> ' : PHASE II GRf3UT INSPECTION 4 I INSPECiQ1�Y $POSE ITI ;FIIVAI. INSPECTION `
<br /> IN PE(�IO V �Y^ ,- - ,— -}DATE,. . �... �/ DATE ,��
<br /> 1 E H 1426 Rev. 1-74
<br /> 1- 4 2MLL
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