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Page 27 of 44 <br /> SAN JOQUIN LOCAL RE"TH oISTRXT <br /> Fa>''0F9ICE ;]SE: � 1601 E, liazclton Ave., Stookenn, Calif. <br /> Ta1uphoa�-. 0264) 466•-67.61 <br /> APPd.;CATIOM GOR WELL DOLN$1RUCTION OR PUKP PLRMIT Permit <br /> THIS PHMMT EVIitLi5 i YBAR M14 DATE ISSUED Date leaned <br /> (C491plete let Triplicate) <br /> ApgiicatLan ie hereby made to she Sna ,laaqutm LacAl Health District for a pstm#t to conetrure <br /> --qudfor install Che work herein deseuibed. This application 18 mode to compiian" Vith Saar Joagtdm <br /> �nunty ordinauce No. 3$62 and the x 'eei and Ragulatima of the San JoaquI Local HeAltR pianist. <br /> i. <br /> EX- <br /> JOB ADDRESSILOCATrON O +L#a AC CE 5E14 CT <br /> Svtier'a Game M,4 Z- <br /> htdeeea SF�r� - 7 .4 --- City <br /> C*nCractvr'a Nazi /, 7 } �.- ' �. �, _ Licaneo l <br /> n Phpne� <br /> -- - <br /> - ....nib <br /> 'YPE Of 'AMA , (Ghack): N,1W VELI,,.jL— —DEUZ5 RJ COMPIT'ION /"7 DF.STRUCd•ION <br /> Pump rmsTALt ATTiDs pump HspA.IR �7 PVMF UPLACEMNT /7 <br /> Other f / ' <br /> .... — — iAj <br /> MTAlNCR TO NI1 U$T: SEPTIC TNS$ SPMR S,INSS PIT PRIVY <br /> SKVAG$ DISPQSAL FIELD COSSPOUL/SEEPAGE PIT O'I'fR jl <br /> ?MPS ` i;� NE - PRI1fA' DOlfBSTIC L.—... PUBLTa D_..,.,•-$TIC WEL <br /> INTE"M 415E TYPE OP WELL CONST$pC'I'ION SPECIFICATIONS <br /> industrial ab'lo Tool Dia. of Well Excavation <br /> Domestic/private Drillad. Dia. of Well Casing _ 12,4.. -.... . . <br /> ➢omeettc/puhl c Drivea Gauge of Cuing <br /> &-- r:Y•Lgacion Gr'eucl Yuck Depth of CrourrSe4l <br /> ........ Cathodic Proteettan Rotary a of Grout., <br /> a7L*Ps5e1 Other a afll>htvm <br /> —Geophysical +Surface Seal <br /> a <br /> PIJMF XNSTAL ATlM Contractd a +�' <br /> Type of _ .. -_. R.P. d Ti <br /> �! <br /> ?nFI'aP REPL.AC1T:� / Seats 'iDar. e _.- <br /> PUV PZPAM- L7 State Noris teras <br /> f6;TjRUCTT0N O;? 1f=. All Dfasrater Approximte Depth <br /> 2eatribe Material &W Pr*zedure <br /> I hraraby agree to campiy with all Laws and regulatigno of the San, To uiln 5cal Health Dlatrict <br /> Ind rhe state of callf&mla pertaimtag to or regulnti'og cell coastrm tteA. Within Fl fdti DhYS <br /> ilft.er c4mp'letion of my work an a Amar call, L vi.11 furrnioh the. Sap Joaquin iaeal Health District a <br /> +fELG. DRILLERS REPORT of the well wid notify then► before putting the mall fn use. The 4berns <br /> information is true to the Seat of pry knawledge and. IIaliaf. II WILL CALL FOR A GROuIi LNSpEC£ION <br /> .PBIIOR TO NG A D h F;NAL mpecrio E. <br /> ?TTLF. <br /> 1y1N PLOT IRAN OiP RSVi:ESE SIDS <br /> FOR 1}MPARTM" 13SE ONLY <br /> PHASE i <br /> ---ZF"CAT1ON A.CC$FTEO BY _ _ DATE <br /> iDDITI(1- 44. CO '):5: <br /> PHASE II GROUT INSPECTIM PHASE III F'I7IAI IINFECTEON <br /> INS]?E=ON RY DATE INSPECTI.ON BY DATE • o <br /> 1426 <br /> 42 <br /> 9/2/2011 <br />