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_ - ,Tg.DISTRICT <br /> SIM JOAgM IXA16 ' Stockton, Calif <br /> Com' E, Raze <br /> Ave. ' 466-6781 T Permit No. <br /> 1601 b : (209) OR PUS' PERMI � �� <br />:F .OFF CE USE: T l-e WELL CpNSTIUCTION Date Issued <br /> • APPLICATION FROM DQE_^ISS <br /> UP t <br /> T ERpIRES 1 YEAR permit to copstruc uin <br /> T�1IS FERMI fete In Triplicateistrict for a witb San Joaq <br /> San <br /> Local1He etionD is made o COOP IIIA�seal <br /> District. <br /> S Joaq S= Joaquin e to the This aFP sof the <br /> Loc <br /> hereby wherein described. g,egu ' tion CENSUS 'QCT <br /> APPllcai tall the work the <br /> and/or No. <br /> No. 1862 and r� <br /> county 6 Phone <br /> TION <br /> JOB ADDRESS/LOCA �, City <br /> 11 <br /> Owner s Name ' ✓ ✓"� _ --"- one <br /> License # <br /> Address <br /> " UCTIO <br /> Contractors Name DEST <br /> "CONN <br /> lViACOWNT --- <br /> NL�W �Lt' /? ION <br /> TYPE OF WORK (Check w INSTALLAT �- <br /> 0 er %I S PIT pR pI -, Mj%R �I <br /> SEWRx L CESS L/SV UBLIC DOWSTIC , S <br /> ST' SEPTIC gg", FIELD STIC SLI' CTION SPECIp'IC� <br /> DISTANCE TO NBA SEWAGE D _ PRIVATE DO1+IE CONSTRU <br /> pgOPERLE U WELL Dia. of Well Excavation <br /> ED USE Ca a Tool Dia. of Well Casing <br /> INTSN,dustrial <br /> Dr d Gauge of Casing Seal <br /> Domestic/Private -' Driven Depth °f Grout <br /> /public ��' Gravel k .type of <br /> -- - <br /> Domestic Information <br /> Irrigation Rotary Other talled B <br /> Protection ----�- Other Surface Seal I�/�• <br /> "�- Cathodic �_ <br /> Disposal- <br /> Geophysical <br /> Contractor <br /> PTALC Type Of <br /> / State <br /> Work Done <br /> PU1+iP REYLACENT• Done Approximate Depth �-.-.. <br /> / State Work <br /> PUMP -_gEPAIR: <br /> Well Diameterretial and Procedure aquin Local Health Dist <br /> ION OF the San within FIFTEEN <br /> DESTRUCT Describe in Local Uealth Dis' <br /> d regulations °well''constru .-Lou. The abov <br /> with all laws or regulatin furnish the Sa` in use. <br /> tee to comply pertaining to I will furn the GROUT INSPE <br /> I hereby ag of California P a new we11, before putting L ORA ---�""� <br /> and the State work °n otify them lief. I WILL CAL . <br /> m the well and n ' <br /> completion U T of se a . <br /> after best of my ITLE <br /> WELL DRILLERS RE <br /> to the AL INSPECrIO E SIDE <br /> information is NG ANDA ON <br /> PRIOR To G (DRA P ?. <br /> DEP TMENT USE 2 <br /> ONLY <br /> SIGNED DATE / <br /> INSPECTIO <br /> ITI FINAL DAT <br /> PHASE � .�- <br /> PHA <br /> APPLICATION ACCEPTED <br /> BY INSPECTION INSPECTION BY 1/!Z7 <br /> ADDITIONAL PHSE II GROUT DATE <br /> INSPECTION BY <br />