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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel toni Ave' .`�'O St ocktoi-., Calif. <br /> Telephone.u."; (209)"l-i-466}6781 <br /> APPLICATION FOR WELL CO' NSTRUCTIONAOR PUMP PERMIT Permit No. 7 Z- <br /> ; - I L/(, � 5 -7k <br /> THIS PERMIT nEXPIRES7,l��Y-RARi,FROM 10DATE9 IS SUED -fr)Dat6�1198u�'d '-77--&'T <br /> I <br /> ApplicatioAp.tiLE§,)htrpby�.Tmade-ito thea5anjJbaquin-','Lo&a1 ne"alih Di stric.t If brla8perhit 2tob 9d6 As tftk b <br /> and/or install the work herein described. Thi 9 k.up�1i cati-aw, mad el in qcomp liance z-,wi th 1�S ati-,;J oaquin <br /> Countyt!-)QrdinaiieeoNo-..ql8626ratd%r thiA;Ru�,,es aatdi,,Regulati7'ons:-)b�,<the.San'- Jo- aqiXXA'�LdCd1;1H alt-h-1 Dls tiict <br /> HT Ujaki, <br /> JOB ADDRESS/LOCATION RD t6i <br /> ',o all k�b� <br /> -10 d.-A no !7. f <br /> x <br /> 711 .-F <br /> Owner!.t!)N'am@1)J ae� 011�10 -6111vt <br /> Address <br /> License # Phone <br /> Contractor's Name SAO e <br /> TYPE OF WORK (Check) : NEW WELL,,K/ , DEEPEN "/ RECONDITION DESTRUCTIONm/ <br /> 7 <br /> PUMP -INSTALLATION '/ PUMP REPAIR PUMP REPLACEMENT <br /> j. <br /> �-O <br /> ........ ther;. <br /> DISTANCE TO NEAREST: ---SEPT1C-TLNK--'- SEWER LINES' ' PIT PRIVY <br /> --SEWA0Z.DISR-O.$AL..FIELD:.. CESSPOOL/SEEPAGE. PIT.: OTHER <br /> 'CONSTRUCT ION4.SPECIFICATIONS <br /> TENDED 'USE':"- "-'TYPE- -OF--WELL'� <br /> Industrial.. . Cable Tool Dia,--p.f. Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing IDA <br /> 'tome s t`t/pub lLd . -DtiVen- <br /> GgVgt' ofCasing <br /> Irr':gaeio ...Gr.av:.al-'P-a'ck,.-;--:,--D.epth,-of Gro.ut;.Seal <br /> Other Rotary Type of Grout 11 <br /> - Inf oiiaati6h" <br /> " - <br /> Other Othd)e <br /> PumO INSTALI-MON:i F' C, <br /> Ty0e..pf Pump 'a.P- <br /> PumP REPLACEMENT i 'Sfat'e' ';�ork Done <br /> PUMPREPAIR: �tate Work Done <br /> DESTRUCTION O'F WELL:6. -- Well .Diameter Approximato- Depth.. <br /> Describe Material and Procedure <br /> I hereby agree to-.comply *ith ,all laws...and' ;egulations of the San Joaquin Local Health. Distric'it <br /> andtthe St <br /> a <br /> te: of' FIFTEEN:DAYS <br /> : Califbrnia ,pertaining to or regulating well construction. : Within FIFT <br /> I.... ..... .I I <br /> after....comip'letilon- of:' my' work on a new well, I will furnish the s7an'"Joaquin Local Health bisiri'i--t a <br /> WEL use. The above <br /> DRILLERS:. REFORT- of the well and notify them before putting the -well in <br /> infq'rmatic;n is true: to: the best:of :.my 'ikn6wledge, and belief.; <br /> SIGNED. ......... TITLE'. <br /> A <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> )U <br /> APPtICATION ACCEPTED BY DATE y=2 <br /> ADDITIONAL COMMENTS- <br /> Z <br /> -PHASE. �II/FINAL INSPECTION <br /> IT GROUT N <br /> PHAS INSPECTION <br /> ��tpn <br /> INSPECTION' BY DATE INSPECTION BY . DATE Q <br /> CALL FOR AGOUT: INSPECTION PRIOR TO GROUTING AND FINAL INSPE6-KON. <br /> 4/72 1M. <br />