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N%dw r <br /> A"' ,):: a e,e Lu i Nvf-, �7,t LIC <br /> A1.1 <br /> -70R. WELL CONSTRUCT'DON OR ?LiMlll arm <br /> T 7111 S' PERIMIT F,.%.P1RES I YEAR ITROJ7:A)' T)AT7, <br /> (Complete In TriplicatL) <br /> :ippiicata on is hereby made to the, San Joaquin Local Health District for a per-init to construct <br /> and/or install the worik. heroin described. This application. is made in compliance with San joaqui,-, <br /> ColLinty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB AODRESS/LOCATIONNSUS TRACT <br /> V/5 CE <br /> Owner's Name "4:) r 0 z:- Phone <br /> AddressJV. "-7 T City <br /> Contractor's Name61 License. Phone <br /> TYPE OF WORK (Check) : NEW WELL R7 TJE---PFN /-7 RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION —PUMP REPAIR —PUMP REPLACEMENT <br /> Other <br /> 7`1STANCE TO NEAREST: SEPTIC TANK f�. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> Depth of Grout Seal, <br /> Other <br /> Rotary Type of Grout y <br /> Other Other Information <br /> ?UST .INSTALLATION: Contractor <br /> Type of Pump <br /> ?UMP REPLACEMENT: J J State Work Done <br /> PURR' REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material land Procedure <br /> A <br /> I hereby agree to cmp lywith all laws a regulations of the San Joaquin Local Health District <br /> and the State of Ca if,rnia pertaining t or regulating well construction. Within FIFTEEN DAYS <br /> after completion o"; work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use.. The above <br /> information-A,s true o he best of:�My kncIIwledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - .. - -- -/�1,7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPECTION PHASr4nIII/FI1AL INSP�ECTION <br /> INSPECTION BY DATE INSPECTION BY 61 VZr—Z&--7 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI4K <br /> F. H 1426 41/2 IM <br />