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JOB ADDRESS/LOCATION,.{ ,��. Hl y /,Z V' je,.JEgj*/1�rCENSUS "_'TACT <br /> Gamer Is Name ! ` O Com, Phase <br /> X. dress City <br /> .Ontractor's Name Ljcense <br /> _PX: <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /'7 DFSTRDGTIox /7 <br /> PUMP INSTALLATION PLMP REPAIR /-7-pump REPLAC30 /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINTS! PIT PRIVT L.. <br /> SO&CE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT oTH81L <br /> { ' INTENDED USE s' r TYPE OF WELL CONSTRUCTION SPWIII ONS ' <br /> Industrial _- ' Cable Tool Dia. of Well Excavation F <br /> r, <br /> Domestic/private �_`.. - Drilled Dia. of Well Casing <br /> Domestic/public Driven Gaul.* of Casing <br /> Irrigation � Gravel Pack Depth of Grout Seal :` <br /> Othe: Rotary Type of Grout v � <br /> s.A. <br /> _ = Other Other Iuforsacion ' <br /> PL:U' INSTALLATION: Contractor, 4-44 <br /> 'tom <br /> g Type of Pump 37H.P. �` N <br /> i'UM? REPLACEWNZ: ,. State Work Done <br /> PUMP 'PAIR: �� Stats Work Done <br /> DFCTRUCTION OF WELL: Well Diameter T Approximate Depth <br /> Describe Material and Procedure <br /> 1 " <br /> i,,•roby agroe to co;:;)1y wit:, all laws and regulat.'.ons of the San Joaquin Local Health District <br /> ,aid t;.c State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> "'tercompletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS RF. of tine weII and notify thew before putting the well in use. he above <br /> informatio i tru6 to f m owleedge�jand belief. <br /> T IT <br /> _ DRAW PLAT PLAN ON REVERSE S DE <br /> FOR DEPARTMENT USE ONLY <br /> P,iASE I <br /> AP?LICATION ACCEPTED BY - ' DATE <br /> Z 73 <br /> ADDITIONAL CG.Linh7S: ' <br /> ?11Aa II GROUT INS C: PyAjj III FINAL INSPEMON, <br /> INSPECTION BY LAU DATE L -15. ..... INSPECTION BY DATE ; <br /> CALL I OR A GROUT INSPECTION PRIOR TO GRO"UTIING AND FINAL INSPECTION. <br /> E K 1426 5/731.M <br />