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SAN JQAQUIN "�O�A "HEALTH DISTRICT <br /> r ----ICE 1601 E. Hazelton Ave. , Stackton, Calif. <br /> 01 <br /> FTCL" USE: Telephone: (209) 466--67$1 <br /> Permit No <br /> APPLICATION FbR WELL CONSWRUCTION OR PUMP PERMIT <br /> a Date Issu. d / <br /> �- i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED�� ^. r d <br /> . _ <br /> ,(Complet.e In Triplicate) ermitt• c nstruct <br /> a lication is made in compliance with SanJoaquin : <br /> ApP <br /> iicatiori is hereby made to the San JoaquinLOHealth District for a P District <br /> PP <br /> and/or install the work herein described. ; <br /> Otdinance No. : 862 and the Rules and Itegulationa of the San 3oaqu3.n Local kiea].t <br /> County CENSUS TRACT <br /> 30B ADDRESS/LOCATION -� <br /> Phone <br /> Name owner's Nam �— <br />` City <br /> Address _ -- .�.. - ;. <br /> License <br /> Phone <br /> r Lic <br /> Contractor's Name <br /> RECONDITION 1 / DESTRUCTION ]- <br /> RK Check) : NEW WELL / DEEPEN 1 / % PUMP REPLACEMENT /� w <br /> TYPE OF WO C PUMP INSTALLATION !J PUMP REPAIR1 <br /> j Q the'r 1_l <br /> SEWER LINES PIT PRIVY' <br /> DIST CE TO AREST: SEPTIC TAN CESSPOOL/SEEPAGE PIT OTHER _ Q <br /> q <br /> pie E05 SEWAGE DISPOSAL FIELD _ <br /> 4' 3 CONSTR[1CIION SPECIFICATIONS <br /> TYPE OF WELL <br /> Cable Tool, f Well Excavation <br /> INTENDED USE Dia. o <br /> Industrial Drilled Dia. of Well Casing h,` Domestic/private Gauge of Casing <br /> Domestic/Public Driven De th of Grout Seal <br /> Irrigation Gravel Pack p r. <br /> Rotary Type of Grout .4 � <br /> Other Other _ Other Information <br /> PUI,,T INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> � - 1'UMI' REPLACEMENT: ,I,�,if- <br /> Stake!�Work=­Done-w_- -lllllll�— <br /> t I <br /> State Work Done <br /> PUMP REPAIR: <br /> Approximatie Depth ._. <br /> ,DFTRUCTION of WELL: Well Diatueter <br /> Describe Material and Procedure <br /> cal <br /> ! I hereby agree to col with all laws and regulations of the SantJoaqu n.LoWithinaFlf'TE tDAYS <br /> and the State of California pertaining to or regulating weI co <br /> after completion of my work on a new wells I will ,furnish the San Joaquin Local Health District well in use. The above <br /> iWELL DRILLERS REPORT of the well and notify them before putting the <br /> � information is true to the est of my knowledge and belie- . <br /> TITLE <br /> &AAX&,L/SIGNED �{D pLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT U5E ONLY �i <br /> PHASE I DATE �s <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO`�NTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 73 <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT{INSPECTION FRI-OR--TQwGROUTING AND FINAL INSP TION. 5 73 1M <br />