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I <br /> . r <br /> LOCAL v •DITRICTi �✓ }) Crrl "_ Lr ► T f�7TG <br /> 4. 1.601 F? ._} tcn Ave, c•r <br /> }'�'� St sk;:o-+ Calif. <br /> T�lephx,c: (209) 466-678i L <br /> 'LICAT ICN' pG ;.ELI- CONSTRUMION OR PUMP PERMIT Permit No. 70 dsj <br /> i` THIS PERMIT E: IBES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> „rr-- sreby made to the San Joaquin T.ocal IIealth District for a permit to construct <br /> and/or - sta11 the work herein described. This application is made in compliance with San Joaquin <br /> Ccunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> --_ C� CENSUS TRACT <br /> Owner's Name ► / f� <br /> Phone <br /> Address City <br /> Contractor's Name License �I - Phone <br /> P-- , >.;= off C2Lk-1-(� <br /> TYPE OF WO1-v, (Check) : NEW WELLDEEPEN /% RECONDIi'ION /% DESTRUCTION /-7 � 1 <br /> PUMP INSTAILATION /PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE 1'0 11EAREST: SEPTIC TANK i t S1 WER L NES PIT FRI`1Y � W <br /> SEWAGE DISPOSAL I:IELD CESSPOOL/SEEPAGE PIT�'� OTHER <br /> PROPERTY LI;:E - PRIVATE. DOMESTIC WELL = PUPLIC DOMESTIC WELL v <br /> INTENDEI) USE TYPE OF t:_F.LL CONSTRUC'L'ION SPECIFICATIONS <br /> V industrial Cable 'Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing �� s' Q �r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal --r <br /> p _SCS <br /> q Cathodic, Protection rotary Type of Grout if�6�l.Tenr r Tom' <br /> Disposal Other _ _ Other Information ��^+��¢� 77-0 p, <br /> Geophysical Surface Seal Installed By: 0611 je ZiwrC_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT_: / / State Work Done <br /> PUMP REPAIR: / / State Work D.:« <br /> DESTRUCTION 0'r WELL.: Well D am�e u~ 2' f i c_ `� Approximate Depth <br /> Describe :Material and Procedure <br /> d <br /> I hereby agree to comply ;with all laws and regulations of the Sar.. Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well. and notify them before putting the well in use. The above <br /> in_ tion is true to the best of owledge and b:aief. I WILL C:1LL FOR A GROUT INSPECTION <br /> PRIOR ROUTING AA'D A FINA 1.'Sr <br /> SIGNED � ' iITLE�--� �� <br /> OT PLAN 01•1 REVERSE SIDE) <br /> — <br /> FOR DEPARTMENT USE ONLY <br /> " P IIA S E �/�ll -- -' <br /> APPLICATION r".CCL'PT'ED BY --i�L�� -- - DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASr. 'I GP.OIT INSPEC'TI:2: - —� PHASE T. i/FT.' L INSFECTION <br /> j 1NSPECTLON 5't D:1TE - =1$�St.CT1.0i; BY <br /> y E II 1426 Rev. 1-7=, 3/16 <br />