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Page 34 of 44 <br /> Sam JOAqUi65 LOM, HEALTH DIS'T'RICT <br /> OF., 0`rt=YCE !1U19 : 1601 E. d92elta9 Aye., nEOCk¢Oft, Caltle, <br /> le;p•hat�a; (209) 666-6781— APPLIC YTON FOR WELL Wt4ST>'Itt4GTIDN CA KKR trERXXT Puratt yo. <br /> Tills pEkrQi EXPIRBS 1 7 FAR FROH DATE ISSUED Date Iaevad <br /> (CoMpleee ':t Trip1j4i*ite) <br /> 2.po!fcntiou is hereby made to eh$ San J'oaquift Local Health Dlscricc for a permit to coristruet <br /> d1'or Lnatall cbe work berafn dcs;Crlbed. Thtu applicat£aa is made in compiiuncd with San Joaquin <br /> unty Ordinance No, L862 �aftd.�the 14ides arerl Rep;LLIatfians a£ ch* San Joaquin I.a•cal Healch ni,strict,` <br /> JfOIJ AnRRs$SFLOCA'FION ll-�"+ -G4•t y,.,c,_ r- 'a''G�c G.. ,{�.y C�ZNSUS TRACT <br /> -air's Name �l P3�ana <br /> J <br /> City <br /> "ontractar's Names f License d l PhortS� - <br /> TYPE of BORIC (check). sew 1&LL �7 DEEPEN RECONDITION f? DES'TRUMON <br /> FUT INSTA LAVON P021P REQrII I f FumP REPLACL'S1L /7 j <br /> oo"t f.f <br /> :STANCE. TO NEAREST. SEPTIC TANK SEEM. LINES FIT PRIVY <br /> $ZWAGE DISPOSAL FF'IELD cESSPOOL/SEEPAGE PLT GTIMR <br /> PAOFP.RTY LINT - PRIVA7rE WMESTIC WELL PUILLIG DGMEST'[C-;4.CL <br /> R <br /> - <br /> INT_NDn USP, 7YPF OF WELL CO}iSTRIICIIflh SP�CIFICIITI{kVS. "rR <br /> Industrial Cable Toal Dia, cf wotl Excavuciara v� <br /> Dome aticl'priviACt! D-dillad Dia. of Weil Casing ` <br /> 4uoeae ic�pul�lic IDriverl Gari a of MLSIng .................... , <br /> . Isrigatios� Gravel Pack Depth of Grout Seal <br /> ow <br /> t�ochndic Pm L`aw.tLC+n Rotary Iygr¢ oaf Grout II <br /> dispoal Othei <br /> sOthar Information I <br /> �s.�npnysical Surface Seal installed Ay: _ <br /> • w <br /> Type of Pump ELF, <br /> YP <br /> PUS' REPLACEMENT: / Stace Work Dane <br /> l3IP REPAIR: f ? 5cace Work trove <br /> .:S.TR�ICSIDtI OF NE1.L; 4cll Dimoutcr �® Anroxi"te Depth <br /> describe .�rseerial aad Prntedure <br /> huseby agree ca comply Wirt all Share nAd regulations of the San Joaquin Local fSealtt► Discrict <br /> id the State of Callfor;tlm pertaining co or regulating well c0vstrueci0n. Within FIFTEEN DAPS <br /> aLtct cotcpLetloa OL my work On a new 'wall, I w111 fvru$oh the Sacs Jcuwquin Local hlcalch DSattirt a <br /> dE1I DRI1.l:MS REPORT of the well and noeify Lhem before putting the well in vise. The ab+ve <br /> -1foz-mation A true to the, `gees of my kpowledge and belief. T_. 'BILI ALL FOR A GROUT INSP'ELTION <br /> :ICIR Fed <br /> CR%EINO .GNU A ' AL 1NSPE !ti- <br /> V-0 <br /> CC'1EkP <br /> TITLE <br /> PLAN_aN_ REuE:isE,saDa <br /> PARI�6EtiT_USE ONLY <br /> MSE 1 <br /> ?PLICATION ACCEPTED BY // DATE <br /> 7DiTItlNl.L Ci}}t}EENTS: <br /> FWE 11 MmtF9PECTLO� I+tH,LSE ILY FIN <NSL'LTG'AION I <br /> INSEtiECiIOK BY -..._..--- OATE -� IN9YfcTrzos SY' ' . DATr' ,✓�'! <br /> V76 214 <br /> E K 1426 Rev. 1-74 <br /> 9/2/2011 <br /> ..........................._.......... ..... ...... ... ........... <br />