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County cb No. 1862 and tha Aida• and Resulatioaa of the San Joaquin Locai Heolth Dia�rict. " <br /> JOB AWRESS/LOCATION 'F'dsuS TRACT <br /> t <br /> Owner's Nam �C< � �.m V C � , ,b w ✓ �i�f Phone <br /> Address .AA Aj-- —u ri` ago 7 .a -S wy 9 f City <br /> Contractor'a Nam License i !?d�Phone a '0- <br /> w <br /> i <br /> TYP}; OF WORK (Check): NEW WELL L7 DEEPER /'7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION PUS REPAIR L�PUMP REPLACEMENT /J I <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINER PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indurtrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> --� ! <br /> Pal? INST.:LLATION: Contractor <br /> Type of Pump i H.P. <br /> 7,v <br /> ?UM? REPLACElXW, : /_7 State Work Done l <br /> t <br /> _ 1 <br /> PL':U' / State Work Done <br /> t <br /> DcQTC.UCTION OF WELL: Well Diameter Approximate Depth ; <br /> Describe Material and Procedure <br /> i <br /> k <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS ` <br /> sifter coaaletion of my work on a new well, I will furnish the San Joaquin Local Health District a � <br /> %;ZLL DAILLEAS R~PORT of the well and notify thein before putting the well in use. The above <br /> information is true to the best ofdge a belief. <br /> SiCSED� / <br /> AtyotITLE 11 s <br /> V /_001W P PLAN ON ERSE SIDE <br /> p�OR DEPARTM NT USE ONLY t <br /> 11-AS"', I r` <br /> ",,,,.POR <br /> �„. :C:C;ON ACCEPTED by <br /> DATE <br /> ii C'iOUT PHAS III/FINAL INSPECTION <br /> by DATE INSPECTION By _ DATE <br /> A GROUT INSf'ECTIOi Pi%ivi< 'i'v GROUTING AND FINAL INSPECT N. <br /> _ . . 5/731M <br /> y <br />