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I'v <br /> 'Qa7( i 7 <br /> Fe Q) <br /> �qEj,!, Cr,,,,Srp'jr 12 <br /> OR pLj al+ '0 <br /> �Ij T V"'P <br /> 1. YEAR 11,7E.01 <br /> I s s-u e d <br /> 0 Mqr)1.C,L e in T;-ipljcate) <br /> is 110rcbY --16J3 �0 the San Jonquin Local District for a pormit to conatruc-t <br /> Ilk-rCia 0!7ig('1_io d. Tr-:?. al pl.,'CaCic-a i3 made in Compliance -ai-th Saa <br /> y No. 18062 and t1 e ruj,2�s and 711r---c of `Ipe Sart Joaquin Local He-althl. T1-',;, <br /> J0;3 AD j-)2 tq S L 0 C A T 10 N V11Z, <br /> CENSUS TRACT ' <br /> T- <br /> -2 <br /> 4( <br /> Add�ess <br /> city <br /> Contractor's Name License # Prone - <br /> 11PE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION PHE TST-R-U-C-T N <br /> PUMP INSTALLATION REPAIR .PUMP fiT <br /> Other 4- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE 'PIY—' ' OTHER' <br /> PROPERTY LINE -- PRIVATE DOMFSTIC WELL '— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of. Well Excavation - <br /> Domestic/private Drilled Dia. of Well Casing R . <br /> f <br /> Domestic/public Driven' Gauge of -Casing <br /> Irrigation <br /> Gra- e I Pack Depth of Grout Seal <br /> Cathodic Pr-otection. Rotary_:,,.. Type of Grout <br /> Disposal <br /> —,other' k� Other Information— <br /> Geophysi-cal. �-.,' <br /> Surf ace*SeAl"Ingtdllda ly:- - - - - <br /> : <br /> 7� <br /> n ractor.. <br /> PUMP INSTALLATION 7" -Cb <br /> Type of Pump-- H.P. <br /> PUMP REPLACEMENT: State 'M-o' <br /> rk Done <br /> PUMP REPAIR: 177 State 'Work"Done <br /> 7 <br /> DESTRUCTION 'OF -WELL., ter <br /> 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 /> after' completfon of my'"work on a new well,-- I will furnish the SanJoaquinLocal Health District' 4 <br /> WELL DRILLERS:-REPORT- ,of the well, and notify tbembefore putting-thd­vell. In,iise..-. .Th <br /> e above <br /> information is true to the best of- my- knowledge and belief,j WILLCALL 'FOR'A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL//INSPE <br /> SlGNE D <br /> TITLE 1" <br /> (DRAW PLOT PLAN ON REVERSE :SIDE 77 <br /> is FOR DEPARTMENT USE.ONLY <br /> PHASE I.- <br /> APPLICATION"ACCEPT My J.1 <br /> ATg <br /> F.ADDITIONAL,'C" OMMENTS: <br /> ­­11-Pft1-1-- +PHM--11 IGROUT -INSPECTION <br /> �PUAA 117,JFINAL-INSPECTION <br /> Mr <br /> 114 <br /> 1 1, 'DATE <br /> i �,4 'BY MATE <br />� IXSPECTION'zy <br />