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- _ - - - -- <br /> SCS ENGINEERS 976 <br /> 415-829-0661 r"- <br /> 8711 SIERRA COURT. SUITE C <br /> DUBLIN, CA 94568 19� 1114 <br /> 1210 <br /> 4Y <br /> 3THE San Joaquin Local Health District <br /> RDER OF I s, 70.00 <br /> Seventy and no/900---_-_-_-_--..----------------------_--__--_._----------_-----_ DOLLARS <br /> SECURITY PACIFIC NATIONAL BANK <br /> San Ramon-Diablo Office #0761 <br /> 2540 San Ramon Valley Blvd. <br /> San Ramon.CA 94583 <br />�R 038900x.00 (503) <br /> 11'0009 7611' � 1: L 2 10000441: 76 Lir 06 34 7911' <br /> "..,. — ,.u. rnone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES - DISPOSAL FLD. - PROP. LINE - <br /> FOUNDATION 251 AGRICULTURE WELL - OTHER WELL 1 2 r PITS/SUMPS-_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial IT Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - <br /> E) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - <br /> ❑ Public EX Other ❑ Delta Depth of Grout Seal - Type of Grout ` <br /> ❑ irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic System permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residenr.R r.,..,.-.�•�.,� ..-�- <br /> r <br /> i <br /> I <br /> i <br /> f <br />