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SMI JOAQUIN LOCAL HEALTH DTSTRI' f. <br /> FOh OFFICE USE: 11* ,.. E. Hazelton Ave. , Stoc:,tc,, , Ct14f. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEIMIT Permit No. 2;?,I#1 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Jgdquin Local Health District. <br /> / el v// <br /> JOB ADDRESS/LO/CAT/IONn 3CrJ(83 � ��i /' � lr) CENSUS TRACT <br /> Owner's Name / , / �/ >�����p�� FIM, `s�/J� Phones 22-�2 7 <br /> Address 1Q/ 6-y. /C /a/1Eie ;I-D L/K . ��fs�s �1CityAldo —/n <br /> Contractor's Name Gs j epwre6 !' S t cuiAnr License l .20l.S PhoneSS? -J x? <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S L v C <br /> Type of Pump u (3, W.- H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT Pf the well and notify them before putting the well in use. The above <br /> information i le o th est of my knowledge and belief., / <br /> SIGNED TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR DEPARTMENT USE ONLYT <br /> PHASE I <br /> APPLICATION ACCEPTED BY i / c,� DATE 6 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO P,6�OALim' INSPECTIONINSPECTION BY DATE INSPECTION DATECALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN. <br /> E H 1426 4/72 114 <br />