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"7 21 C" : }x'� u <br /> 7. <br /> SM:JAQUIN LOCAL HEALTH DISTRICT <br /> 1601EHa telton Ave r� �' <br /> t�`L FOFs OFFICE.USE r , S tock.on, Calif <br /> (204):,466=678 <br /> 4 <br /> APPLICATION FORL.WELT. CONSTRUCTION M.PUMP PERMIT" 5 Festinit Hai <br /> TaIS PERMIT=EXPIRES 1`''YEAR FROM DATE ISStfED `` 4 �ateIssi�ei' <br /> �; r, - (Complete -Im Triplicate).? R ��, • " r 1: <br /> Application is hereby made -tothe,San .Toaquin Ldcal health Di stricfoxa�►ertttc } <br /> aad/or. install the, work.hereia described This application is made,, t ccmp?3imre <br /> County Ordinance Na 1862 and-.. Rules and Regulations of they Sas Jaagniiocal� r ei <br /> 50 <br /> JOB ADDRESS/LOCATION <br /> w <br /> p <br /> ,, r Uwner s TVame' s' <br /> rM <br /> - -Address s` � <br /> wCi�t <br /> Contractor's Name License<# P1xa <br /> • .r x� y Kms° ` ' <br /> r RECONDITION D STRFJCTIOI s. <br /> t <br /> -TYPE OF WORK c) NEk WELL � DEIPEN /�". I <br /> PTJMP INSTALLATION / PUMP REPAIR � <br /> /'/ ( PUMP REPLACBNENT _ ''<f <br /> � � s Other <br /> 'DISTANCE TO NEAREST:,,:' SEPTIC TANK EWER:LIAES: fi.EIr <br /> 1DSEWGISPOSA:`L F ELDW D E SWPEOLOIL.;/�SE 'PAPfUB..II n <br /> PIIVATE:DOMESTIC ESTtCTDRPROPERTY LINE <br /> p <br /> ri INTENDED USE TYPE QF=.WELL :;- + -CONSTRUCTION,-,-SPFC iICATIONS' <br /> t In trial Cable Tool Dis of Well Excafttfoxt r '� sem• `F <br /> . amastic rivate Dxil3ed <br /> p. <br /> �� Domestic/pu4ilie Dr ers F}� fi Gauge of Casings <br /> �, Zrrigatfon= r 1 Pack Dep*h,of'.�Grout:S �� c�� <br /> Cathodic Protection �Rotarg4 Type of rGrout R <br /> sOthpr} Ofher'Iaformation r:' N . <br /> r ;Geophysica3 ' -- `a ` x Sui`ace:$eat= iistalled r "`` - <br /> ,.... <br /> 5l�UlTF�iNSTAI.I;ATION Cbmtractory ;• .sem <br /> x Type of: Pump m' <br /> rY>z �REPLAGP.3�EN"P. � '/_/ State Work Done r" r '=� Yom` �"� .�-�"...��•��,}�_����� __ � ' <br /> PUMPTtEPAIEt /7 State Work Done >rvfssu- � �- n' �' <br /> BESTRUCTIONOF,.WEI.ir WellDiameter $ .;. proximate pe <br /> �} Describe Material andrProcedure � f E . fig <br /> -'r. _ - { - r Z _ -<.• ,,� 9,%17r 3 t:i!f"5a.`_'rz'-.-31�"''�fp�>rµ "n ` > <br /> l herebytagree to comply with all laws and regulations of the 5am3oaquin LocalfNelthior <br /> and the State of Cali£flrnia pertaining to or regulating well,consru � thia <br /> 3after campletioa of ay`work oa a neW,weilr E will rriish tha San�" oa �o �� to <br /> WELL'I3 LT,ERS RT3PORTwaf 'the we11 and uatifq them beforesputtiugtiewve33uste� e <br /> Li forma u:1s true tc;the best rxledge and belief L S;rrrs• CAL �FORrtAyGBL1[1 " <br /> RIOR'>- DTING,'AND A'e N <br /> SI <br /> , , _ PLAN.UH:B.EVERSE: 7 ILII '}-r:d,: .•4- S'�.1,C_'�ti+f�PS�' <br /> .- <br /> s APPLICATION':ACCEPTER BY <br /> ADDITIQNaI. Ca:+4MENTS <br /> ., I GROOT I3I5PECTION ,� ,PD L -1/FINAL'INSPECTION, <br /> 0 T3Y. DATE 6-.� INSPECTION BY' ,:DATE <br /> INSPECTI N - -:,� <br /> 3 <br /> 1 x 0! <br /> L <br /> 1-74 e s o-, t9 b y Ci r ? <br /> E'•Ti 1426• Rev: :s - .:r ): ,.�..-r- .� 'r <br /> ` � .r i,�#.'-3a-da+.�' _`'eY x r. 'r^....r t x�� �.�r�'s ��.e,��.✓ i .>� 4s. - �-'t - r � '- `l. <br /> ' z.•tJi � _:' - _ �^^�` �' ay,r r'-�-+Y.t• }.r-.moi�`£?tM+"*-�''-. ��jr'. <br /> f.,.T,',.' Y .ei w� 't4 •h^" 1 7,` J Y y Jf+-1 �•-*..i <br /> h <br /> ;'I <br />