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THIS EXPIRES VATE 1S;;UED —1 <br />(Complete In 'Trip? ..Y) - Date Issued <br />Application her_ made to the San Joaquin Loc a <br />a <br />County Ordinance No. 1862 and the Rulpl Ilea_ <br />and/or install the w,.k herein described. This plicaticnDistmade inrcompl ancea permit tr,'ithnSan Joa <br />es and Regulations of the San Joaquin Local Health Diet--. <br />JOB ADDRESS/LOCATION <br />CENSUS TRACT <br />Owner Name GG)�� <br />it <br />'0011 <br />Phone <br />Address <br />Contractor's Name S � ) City 7T <br />- <br />Licenue B Phone <br />Tk IF WORK (Ci.eck): NEW WELL 1-,T DEEPEN /-% RLCUNDITION %% DESTRUCTICN f7 <br />PUMP INSTALLATION /% ,p?pT REPAIR /-7 YUI[I' REPLACEMENT /7 <br />Other /7 <br />1DISTANCE TO NEAREST: SEPTIC TANK_`—"�-� <br />SEWER—LA. -0r, 0 PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEF.PACE PIT <br />PROPERTY !,INF. - PRI'�ATE DOMESTIC OTHER <br />INTENDED USE TYPE OF WELL LL — PUBLIC DOMESTIC WELL <br />Industrial CONSTRUCTION SPECIFICATIONS <br />Domestic Cable Tool Dia. of Well Exc <br />_ /private Drilled avation. <br />Domestic/puWc Driven Dia. of Well Casing <br />Irrigation Gauge of Casing <br />Gravel Pack. <br />Cathodic Protection Rotary Depth of Grout Seal <br />Type of Grout <br />Disposal Other <br />Geophysical _ Other Information <br />Surface Seal Ins�slled By: <br />PUMP INSTALLATION: Contractor -- <br />Type of Pump `- -- - <br />PUMP REPLACEMENT: <br />- / / State Work Done <br />'UMP -"AIR: /% State Work Done <br />„_.'.STRUCTION OF WELL: Well Diameter <br />Describe Material ar,d Procedure Approximate Depth �e�0� <br />1 hereLy agree tc comply with all laws and re�ulatic�n of the'San Joaquin Local Health Distrix: <br />and the SL*Le of California pertaining to or regulating well construction, ioithin FIFTEEN DAY'; <br />ifter completion of my work on a new well, I will furnish she San Joaquin Local health Distrir.:t <br />•,'FLL DRILLERS REPORT of the well and notify them before uttind the well in use. the above <br />:';tl0ii TO GROUTING A F� AL NSPECCION. <br />_nfoematioa is true to the best of my knowledge and 'hel,ef, I WILL CALL FOR A GVOUT INSPECTTi,ii <br />TITLE— <br />(D ,O EVERSF SIbE) _..._. <br />�- - - - _ _ <br />FOR DEPARTMENT USF -ONLY <br />�'i{ASE I _.-- <br />.n: PLICA? ION ACCEPTED bi .j <br />i.-DDITIONAL COW..ZNTS:_ DATE <br />PHASE I1 GROUT INSpFe-r I0!. - <br />''i�� <br />: III FINAL TNSPECTIO�N-._.. <br />:;SPECTIU:: by ---- - DATE INSPLCTICN I;%_ <br />- ---- DATF. <br />-• 1 .. . <br />