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<br /> SAN JOA UIN LOCAL NE 0(ap
<br /> FDR OFFICE USC: ! AL£Fi AISTRICT
<br /> " 601 E. Hazelton Ave. , Stoc.,tor., Calif. �J
<br /> Telephone: (209) 466-6781
<br /> PLICATION FOR WELL CONSTRliCTION OR PTT:D' PERMIT Permit No. C
<br /> 1f a, >,9�, ! FiIS PERMIT EXPIRES 1 Y:fit FROM DATE ?SStJEA Date Issued
<br /> (Com y'
<br /> e:@1;-'r',. ,�•'i —.._. ----
<br /> plete In ,Triplicate)
<br /> r s a Application is hereby made to the San Joaquin '.ccal Health DiaLr'ict. fpr a permit to construct
<br /> and/or/ install the work herein described, ir,, ';'` •�"`�..•� application is made in compliance'with:Sati0aaquin
<br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health=District.
<br /> (4 H
<br /> �11SSa .IOB ADDRE5s/LOCATIbNr� trjrj -Arn . CENSUS TRACT: '
<br /> ..r '�
<br /> Qt ,v Owner's Name
<br /> "► + ''.Y��erL- - - .,_ -- Praone X369-7845
<br /> ria a�
<br /> Address .-- - w n
<br /> F.74e Citi r a
<br /> y "X;V,, Contractor's Name
<br /> •-`r i l.� "n - -- __._. License !! ?bone, 369 t347I
<br /> fay TYPE OF WORK (Check), NEW WELL DEEPIW 17 RECONDITION /7 DESTRUt'TION f7 -
<br /> r. s:
<br /> PUMP INSTALLATION / / PU�li' REPAIR'/—/ PUMP REPLd10EM$NT /7
<br /> A ° Other
<br /> "r I -
<br /> a.
<br /> M� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY
<br /> , -6 SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT ?
<br /> ..Y INTENDED USE, TYPE OF WELL , .b
<br /> 94"� �,; CONSTRUCTION SPECIFICATIONS' q
<br /> Industrial JCC Cable Tool Dia. of Well Excavation
<br /> �� Domestic/private Drilled Dia', of Well Casing 811
<br /> Domestic/public Driven '- "T
<br /> .,� Gauba of Casing l2 .P s, (�
<br /> Irrigation Gravel Pack Depth of',Grout Seal
<br /> y' •s. . -
<br /> i�
<br /> L Other Rotary Type of Grout
<br /> 4yf4K{� Other Other Information
<br /> i'L'AP INSTALLATION: Contractor
<br /> V. -
<br /> f Type of Pump
<br /> H.P.
<br /> 21Mi REPLACMIENT: I / State. Work Done
<br /> 'A?9'- � :PUMP_RE-PAIR: / / State Work Done �
<br /> r , XESTRUCTION OF WELL: Well Diameter A ro :
<br /> Describe Material and Procedure I;P ximate I?epth
<br /> I hereby agree to comply with all laws andregulations of the San Joa uia Local Health District
<br /> Ara 1
<br /> ,g ` ;s, and,the State of California pertaining to or regulating well construction. Within FIFTM`DAXS fi.
<br /> after completion of my work on anew well., I will furnish the San Joaquin Local Health .bisErict a
<br /> ti WELL DRILLERS RF-70RT of-the well and notify them before putting the welkin use. Th."Acive !
<br /> ,�UA �U ";.i information is trice to the best my kno edge and be ef,
<br /> � VIO >
<br /> t oft SIGNED ITLE
<br /> PIAT PLAN ON REVERSE SID
<br /> fi4e rv?i . FOR DEPARTMENT US
<br /> W+ i k PHASE I'
<br /> A
<br /> 4r r� A PLICATION ACCEPTER Byoe
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<br /> .ADDITIONAL COMMENTS: DA
<br /> =4+ r�5 PHASE II GROUT INSPECTION
<br /> IriSPECTION $Y DATE INSPECTION BYHASF. I I/FINAL INSPECTION ca-m
<br /> DATE -7
<br /> ' C,`LL FOR A .GROUT_ INSPECTI0N PRIOR TO GROUTING AND FINAL INSPECTION,
<br /> E H 1426 �. 4/72
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