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FORIOFFICE USE: SAN JOAOIN 'LOCAL SHEALTH DISTRICT <br /> 601 E. HAzejtojj.'-Avd.�, rSto`c'kton, Calif. <br /> Telephone:Q-,(209) 466'-6781 <br /> APPLICATION FOR WELL CoNstkbC"TION OR PUMP PERMIT Permit No. ;)S-4)741 <br /> THIS PERMT+EXPIRES. 1,-,YEA-R,'FrROM---DATEt41SS-UED ��O Date <br /> Loqun-,�(Complete jn t2fj-plicate) <br /> Applicaiion' is' 'herebLois <br /> made to the San Joaquin,.Local;: it 0 <br /> and/or,install the work herein described.,e,.Th.is -appl j1ea'ith ,Djg�trjCe.r. or a-zpdrmit 0_�e iU;ttU_Ct <br /> kation ,is 4n,.zompl-i-aned *1th,,Sat1:Jd­aquin <br /> made <br /> County4"�"OF`din a-nice No.. 1862g -Auj s .,..And­]RegU.lationg', ofg the-v-San.�J­oaquin�,L c I I Realiht District. <br /> e <br /> .. ..o a <br /> � <br /> JOB ADDRESS/LOCATION FVl vi <br /> ?&(T A2�,�, �CENSUS I <br /> TRACT <br /> Owner's Name <br /> Phone <br /> City" <br /> C0tract6r,ls Name <br /> U <br /> ce�nse <br /> , <br /> Ty <br /> PE OF WORK (Check),:, NEW-WELL '. <br /> /ZT-. tDEEPEN: 7 REc6Ni)iTI6N- - <br /> L, E <br /> 7 D MiXTIONf7- <br /> PUMP!,INS TZL&IObj PU)T <br /> REPAiR Pump <br /> et- /77 <br /> '0 t-h REPLACEMENT <br /> DISTANCE TO NEAREST: iSEPTIC <br /> TANK " SEWER- LINES <br /> Pi <br /> PRIVY <br /> EWAGE AISPQSAL <br /> /SEEPAGE PIT--- .! OT <br /> "PROP CESSPO4 A HER <br /> • PROPERTY ;.1,14E PRIVATE ST PUB <br /> 'INTENDED USE j -TypE t'W'DOMESTIC WELL <br /> OF WELL tOINS�RUCT�10N SPECIFICATIONS <br /> '-Iildu, .1 I _; . SP <br /> si <br /> F. �, aVl7eTOorl Dia. sof :Well Excavation <br /> stic/ Drilled Dia. �of '.Wel:l Casiilg <br /> me PriVate' <br /> Domestic/public� <br /> 'DriVe* GiuS6 of Ca;sin-g , <br /> 'Irrigation <br /> 1, Pa�ck Grout Seal iGrave Depth of <br /> Cathodic <br /> _ ProtectiofiRotar <br /> y - <br /> Type, <br /> of :Grout' <br /> it0thBr ether <br /> Information, <br /> Geophyaicaa­ <br /> Surface Seal Installed <br /> PUMPINSTALLAT16N: : Co�ntractor <br /> Type ;of -Pump <br /> H.P. <br /> 7 <br /> PUMP REPLACEMENT: <br /> Lj :State Work Done; ...... <br /> J <br /> PUMP, REPAIR: - L7 <br /> :State Work <br /> .RES1kVdTION OF WELL;" Well 'Diameter f Approxiaat-e Depth <br /> 1-a-f-and -Proce�dure <br /> -Describe: Mater <br /> I hereby agree to complyW � Wlllawb and regulations of the Sa <br /> n;Jo&quin Local Health District <br /> and •the�State' -Oi California ;pertaining tb ,or -regulating hi" - DAyS <br /> a 9 well construction. 7''Wit n -FIFTEEN <br /> after 'Completion of m: work 'o <br /> wEd'bkLLtR" 7_ q . a, new well,, 1 will. :furn: ish. the San,Joaiqui.n Local- Health District a <br /> ORT of the .well and notifythem putting the id use..ore pu <br /> informitip' n is tru4 ,to t�e-be_ e.. : Thd above i <br /> e o st�"of­mylkn o"wl;4dge' <br /> PRIOR TOG IN AND A FINAL :INSPE:CT ' WILL CALL' FOR`A GROUT PECTION <br /> SIGNED <br /> (D <br /> TITLE-, <br /> -(D W PLOT ;PLAN O-NUVE1 <br /> ISE-.SIDE <br /> T.USE, ONLY <br /> PHASE .I <br /> MEN <br /> UPLI-CATI46N ACCEPTED PTE�1) B�y <br /> 7 J <br /> DATE <br /> ADDITIONAL COMMENTS:i. . <br /> `PHASE UT jNSPECTION PHASE III INSPECTION <br /> INSPECTION BY, ::7 <br /> INS <br /> B PECTION <br /> BY DATE <br /> . 1-74 .5, <br /> E H 1426 Rev. <br /> IL 7 <br />