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5AN JoAQVI" W00j. SMALTH DISTRICT s f <br /> • 1QC:OFFTCV USE: 1b01 8, Haactltoa .&C., SCoCkton, Calif: <br /> Tolephone; (204) 466-6181 <br /> APPLICATION FOR WEI L CONSTIt=TON bR PUW PBT.41T Per:sit !ro.&_lS�_i l <br /> THIS PMUT E7SF13SkS 1 YEAR FROM DATE 15547Si1 Date Ixaeted 7d <br /> So�e7T�• Pleto In Triplicate) Gr► 2�FS-t&0--.r,! <br /> Application. is hereby rade to the San Joaquin Local Heald, District for a parmit #a coasrruct <br /> endf6i inatall the work herein described." This application IS mads .in cdZPlianCe with Sari Joaquin <br /> County Ordinance No. 1862 End the Rules mad <br /> �Reeguullati/ons of the San Joaquin Local Healt7, District. <br /> 5L4 /K -/ied_ <br /> .IO$ ADDRESSILOCATIOyy � '.+w fr-e� 1t CENSUS TRACT" - <br /> r + <br /> Owner+a Nano Phone <br /> t_ City <br /> Address - <br /> Captraetor's Nano Y CCAre eulAknonso I A&/1 ~, <br /> 'TYPE OF WORK (Check)t h V 11.m DEEPEN'1J R8MMI'T.ION 17 nwimiOC•CYoR /7 <br /> PUMP INSTAL)ATIoM L-7 Ptiw REPAIR-,g REPLAc exi 17 <br /> Orhar 1-7. <br /> DISTANCE TO NHARRST: SEPTIC TANK SEWER LINES PIT 'PRIVY <br /> SEWAGE DISPOSAL FIEW CESSPOOUSFEPAGE PIT arm <br /> MENDED USE TYPE OF SWELL CONSTRUCTION SPF.GIPICATIONS {h <br /> Industrial ° Cable Tool Dia. of Well Excavatica <br /> Damearit/private _ Drilled DLL. of Well Casing <br /> boepeocic/publ:ic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other loformation <br /> PU.V INSTALLOLTION; Contractor <br /> 'Type of Pur, <br /> PUMP REflY.ACBrOiHi's 11 Stato-Work Dona <br /> PUMP 9EPAIR: 17. State Work Dona <br /> Ph <br /> aDFAI�RUCTION OF WIML: Wall Diameter. Apprextuate 'Depth <br /> � Describe Xatariai tmd F.rocednre <br /> I hereby agree to coopli with all laws and regulotiorw o Me San Joaquin Laeal Health Diatrlct <br /> .and the Stote oP California pertaining to or raguiatit,g well construction. Within F1 ERN RATS <br /> after tonpletion of my work on a new well, I will furnish th4 $44 Joaquin Local Hoalth District a <br /> WELL DRILL09 REPORT of the well and notify then before putting the well 4a use. The above <br /> information is truo to the best of cep knowledge and belief. <br /> i SIC"D TITLE <br /> oL <br /> DRAW PLAR PLAX ON REVERSE SIDEY. <br /> R DEPARTM'bIr T USE 4%'4LY <br /> _PHASE I <br /> APPLICATION AC�CEP'iBb BY _ _DATE z <br /> ' ADDITIIONhL COMNEN S: , <br /> M- II j9ROUT 'INSPECCIOt€ PiIASE III FIi�AI. 1NSPSC7i.ON <br /> s <br /> II95FECPI03f BT. - DATZ Z IxSPECl7A?7 BY DATE , <br /> CALL FOR A GROUT rXEPECTION PRIOR TO-CROUTING 4649.YIXAL 114SFBC 109- <br /> R H 1426 <br />