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I I GT <br /> T. <br /> .:%1-1 ')PTE TSS_4ii X, <br /> (C,k jajt-�te_ Tn Trip1 *.Cato-) <br /> 1,7;,1 ti un is '.,ereby i,-ade to L11C. Sant3iYl Local 111cealth 'District for a permit io con­si;ruct <br /> 5tio- mada j-11 col,1pli.ance San Je <br /> --fa described. This applicr n is <br /> i ( nstall the work here., <br /> ordirance Na. '1862 and: lie Rales and 'Regulatio-,ns of tha Sar jonquiln Local Eeaklth D­'sti <br /> - <br /> JOB LDDRESS/LOCATION 4337 Fars St. CENSUS TRACT <br /> re Sto&ton 1;n-1-tied Sc�nc.�l Diztxict Phone 466-201.i <br /> Grw�c�i2E,s NN,�lL <br /> liddress City a <br /> Contractor's Name World -Enterprises License # 265964 Phone <br /> �6,6 6 I-T <br /> TYPE OF WORK (Check} : NEW WELL DEEPEN '/ RECONDITION DESTRUCTION "-1 <br /> PU]kT INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> 40ther LAI Q112 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . 'PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -----CESSPOOL/SEEPAGE PIT__W,� OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable TooI <br /> Dia..-of Well-;,.Excavati.on, <br /> Domestic/private. Drilled Dia. -of Well-Casing, ' . .,., <br /> Domesitic/public 'DrivenGauge afr 'Cagi <br /> Dep.th..of ,Grout-.,Seal._ <br /> Irrigation Gravel Pack.-. <br /> Cathodic -Protection Rotary Type-of Grout <br /> Disposal other Other Information- <br /> Geophysical.. to__ __Sidrface .'Seal -Installed By.:. <br /> %j <br /> PUMP INSTALLATION: -'.. ,Contractor <br /> Type, .of, Pump H <br /> State iW6-r-IC Done <br /> PUMP REPLACEMENT <br /> PUMP REPAIR: .!-State:Woik Dond" <br /> DESTRUCTION OF WELL: V <br /> -; ell_Df-ametei.1---'_' ....... 'Depth <br /> Describe Material and Procedure fill w/neat cement P"our -sap over casIng <br /> 3 'A.­'below <br /> I --hereby agree to-comply with,-all' laws-and«regulations_of the Joaquin Local Health District <br /> and the State of California pertaining to or iiz"egulating well '"construction. Within FIFTEEN, DAYS <br /> 191i"' ' ' '- <br /> after completion of my work on .,a new-well, }I <br /> wx ifti -t1f6 Sdri Joaqilin'LocllHedlth' District a <br /> WELL DRILLERS REPORT of -the we-11-and notify.tli.em .bef ore putting the well in use.., ,'The above <br /> information is' true to the 'best of. - my knowledge And belief. I WILL CALL FOR A GROUT INSPECTION <br /> ----------- - <br /> PRIOR TO-GE2MNG AN;) ,A FL I.,,NSPECT lON. <br /> SIGNED <br /> Co-Owner..--- <br /> RAW PLOT <br /> PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT:, USEONLY <br /> PHASE 1-Y <br /> ACCEPTEDI DATE <br /> APPLICATION; <br /> ADDITIONALMNMENTS: : ;jC I <br /> ECTION <br /> 1i; C� FA '.BY <br /> -H�142jee <br />