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Page 36 (i[44 <br /> fv i SAH 30Aqi]IR LOCAL REALAl UTSTRICT <br /> FRFi i►PFZGE CF H: 1401 E. NRZelton Ave., Stcekton, Calif. <br /> TalePhcne: (TOS) 448-6781 <br /> APPLE CATION FOR WELL CONSTRUCTION OR PUMP 110MI7 Peruxit Nn. <br /> TRIS PERM= EVIRHS 1 YBAR FROM GATE IS3UEU nate Iadved <br /> (Cmglete Id Ttiplieste) <br /> ApplLeation 1s ber by made to the San Joaquin Local Health piatrlct for a permit to construct <br /> ..and/or inetall tha work herein described. This application is spade is compliance With San J4OOgodr' <br /> ,c+uu�tt�y Or4llzasttee No. 1867 qud the Sulms =d RegulatlQuis of thn San Joaquin Local Health District. <br /> ros ADI► sslLacxtoN ,d 1 d I N A E w. cxsus TLLAGI 0 ?- Oe)-07 <br /> 'wner's NOW r] ✓ L 1 C d cyl. Pafaaa ,_ L fJ �_r� <br /> aarcita 9 4 3 Pt)-7-cR R<L city AC t,- p a <br /> Coatrafirpr`tt hTsme >�4-T- r� M1 i L.icenac 6JG 1 ? Phasie � 3 <br /> YPH of w0M (Chack): iFw wnL L7 DRHREN /-7 ucoNoI'TiOH 1-7 uE5TAucrrON r7 <br /> PUMP INSTALI ATION M mw RSpAu /-,7-0tw ICEPI.A T L <br /> Other /J <br /> ISTANCE TO NEST: SBl►TIC TAN-X $0MR I,Z'M P1`T PS-0 <br /> SEWAGE DZSPQSAL FIELD CESSPWL/S85PAG PIT F,7tMR <br /> PR{I�'E81Y I INE - P TVATR fl[MSTIC L— PUBLIC w STIC WELL <br /> itiT�ll1$p L1BF TF8 OF WELL CONSTRUMIRN SPEC11FICATIONS <br /> Tudustrial Cable Tool 31a. of Well Excavation <br /> y DoisCic/private Drilled Dia. of Well Camas - -- i <br /> Ooufastle/public Dr2vea Gauge of Casing <br /> lrri.gatton Gravel (Pack Depth 4f G=out seal <br /> CarbAx.ic Pratectie;a Rotary Type of Crout <br /> - Disposal _ OtherOther Information <br /> -OeoPhysia l _ S>' Agee SaeIasta S ; <br /> PUMP INS•TALLM-ON. contrAeter 4- P. kir. F <br /> TYpa of Pump H.F. I C <br /> " T <br /> Jl9P REPLACMIM: /7 State w*ck oone <br /> PUN?1EPA112 1-7 State Work Dune <br /> LS• UCTIDmp OF WELt,: Well Dianstar #approximate Otpth <br /> bemcribe Material and Frocedurt <br /> I hereby agree to comply with all lava and reguulativns of the San i"quia tje l Health watriet 6 <br /> id Cbe State of CalitmrnLa partainfng to or regulntigg well Conatrueticn. SLitbln FIFrM DAYS <br /> :ter completion of mF hark on a new well, I will Eurnish the Suit Joaquin local Realch District a <br /> 'LL DRILL RS aSPOR'T of tKe moll sad xtotifyr them before putting CTO Well In tsaa_ The above <br /> information 1A VAW rep the bent at my kncvLedge and belief, I SPILL CALL FOR A GROUT jVSPELTIt3N <br /> PAIOR TQC A F AL tNS CI3AIi. <br /> GBa TITLE -927 <br /> RAW PIAT PLANw ON REVERSE SIDE <br /> FOR n"ARTMY.ELT U33 ONLY <br /> a <br /> PHASE T <br /> �.RP1.xCATIZN ACCEPTED BY DATE -7 C <br /> DITIONAL COMMENTS. <br /> PHASE II 6RWT INSPEMON PiRs6 271 I+IKE II NP—Poral <br /> 4N&F11=1GN 6Y LtA4k ttispEcrro" Eti DATE '/6 <br /> LV <br /> 8 u 1426 Rov. 1-74 ti 1-744 lbs <br /> 9/2/201 1 <br />