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QS <br /> jP <br /> C t'j SAN' JOAQUTN LOCAL HEALTH DISTRICT <br /> F05 .OFFICE USE: 1601 E. Hazelton Ave., S'_"kton, Calif. " <br /> Telephone: (205) 466-6781 <br /> APPLICA2I017 FOR WELL CONSTRUMON OR PUMF PEiIifIT Permit No. <br /> THIS_ER,`111T EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> (Complete InTriplicote) <br /> App L'cation is Gere madetothe Sat: Joaquin L,;cal HeelCe Dist:-lct "or a permit to construct _ <br /> :..and;or install the work herein described. This applicatioa is ;'made in compliance with San Joaq x <br /> Cct.,ty Ordiaa.nce No. 1862 and the Rules and Regulations of the San Joaquin Local: Health District`,`:e,, <br /> JOT; E,lii:SSS/'•OCATIO' { t _ R/�-7 ,i(_i its CENSITS 2RAFCT <br /> .Ow l•er's Name s:. 6ti,t.-' ,E, _�.e•V—i�7.s� �'' �_. Phone <br /> e� r <br /> ' Mdreao _��!} iv—Ye(�J^I City 6-A� <br /> Contractor's Nazr2 ^i/ ,��_(�.�+yr/ <br /> License S�( ULL pheme�'��.� <br /> TYPE JP. WORK Che;k):. ;.r.W 'r.EL), – _ DEEPI2I 7 R7iCONDITZON ` <br /> �,.. PL'PL° INSTAL ION / PUMP �E PAIR /% PIMP REP'i.ACEi'II:NT 1 <br /> p . p <br /> Other jfy <br /> DISTANCE TO °EPTIC TANK - SEWER LIMES PIT PFIVX <br /> - - SEWAG% DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPF,RTY LINE --PRIVAS_E DOMESTIC WELL . PUBLIC DOMESTIC WEIL <br /> INfi _W;0_-USE TYPE OF WELLONSTRUCTION SPECIFICATIONS <br /> Indo=.t:te:l. Cable. Tool Dia. of '•I_ll.Excavetion <br /> Domeretic/private Dr?lled Dia. of Well Caving <br /> 3 Domes Vic1public Driven Gauge of Casing <br /> _ _ Irrigativa Gravel Pack. Depth of Grout Seal <br /> W_ Cathodic Prof ectian Rotary Type of Srout <br /> ' <br /> --Disposal Other Othex Information - <br /> Geophysical Surface Seal Installed By: _ <br /> F001P' INSTALLATION: Contractor <br /> Type of Prwp - - �'' la•-+.r,�' _ H.P. <br /> PUMP REPLACEMENT: - / / State'Work Done -- <br /> µIIAtP REFAlR: % J State Wotk Lone <br /> DES�V^T_CPION OF G_ELL: Well Diameter Apprczimate Depth <br /> uaacribz Material and 7roce9v.r. 3p' <br /> ¢J I hereby.agree '.o comply with all. laws and regulations of the San Ooaquin Local Health W.stric <br /> and the State of C&Ii€ornia pertaining to or regulat,'.ng well'construction. IiAthin FIFTEEN ;.AYS <br /> after cospletioa of my work o•.i a new well, I will furnish the San Joaquin Local Health District ea <br /> •� WELL DFJ L:ERS GEPORT of the well and notify them betore putting the well in use. The above - <br /> inform r _cln,� true to the best of my knowledge and belief. `WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TQC ',EilUT:M AND ljiR-EIN CTION. .� , <br /> SIGNED f_•- :.trL_ _v''e.. TITLE �., <br /> ON RERE SIDE "• ''"i 4 ii; <br /> .ia .aa POI: DEPARTIIE°iJTUSE ONLYc -� • ' <br /> JFLI; Y <br /> .F'?LICATI01 ACCEPI'LD SY �.e� �_ DATE <br /> - tDDITIONAL CCIVENTS: �J <br /> ?EASE 11 GROUT INSP .PHASE III FINAL INSPCC�TTII�QI�__1� <br /> INSPECTION BY� �•__ DATL _ _- INSPECTION By—/_1 DATE �'� . <br /> f <br /> 2M a. <br /> E H 1126 Aev. 1-7 3/76 ,ns <br /> y ' <br />