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]� <br />SACT 3Oa1+QUiN LOCAL HEALTH iil5TitIGT <br />FAr:OFFICE USL: 1601 E. Hazelton Ave., Stockton, Calif. fVIA <br />Telephone; (209) 466-6781 ' <br />i <br />APPLICATION'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Hate Issued <br />i (Complete In Triplicate) <br />Application is hereby made to the San Joaquin Local Health'District for a permit to construct <br />and/or ins all the work1herein described.- This application is made i ompliance.with San Joaquin <br />County Ordinance No. b2 and the Rules and Regulations of the 5at� Joaq n Local Health District. <br />' t �A &In t SUS TRACT _ <br />4 <br />i � Y <br />Owner a Nam Y Phone 17,p <br />Andress . City.. <br />- -••w. '"`+- .r..�iY.wr+.rr° r' .,,.r.w. w.r w. .w...w „r,.a.,, .. .. _ _.._ ._ "'".vw� <br />Contractor's ;Name _ License Phone, <br />TYPE OF WORK (Check); NEW WELL / DEEPEN /-7 RECONDITION � / DESTRUCTION J j <br />PUMP INSTALLATION %� PI,'MP REPAIR /� PuMP REPLAcaegT /7 <br />Other `L-/ <br />TO NEAREST <br />SEWAGE <br />INTENDED USE <br />Industrial <br />i'Some s t i r/ p r iva t.e <br />Domestic/public <br />Irrigation <br />Other <br />Drilled <br />Driven <br />' Gravel Pack, <br />Rotary <br />Other <br />PUMP INSTALLATION: Contractor' <br />Type of Pump <br />-P UMP- REPLACEMENT > _ /- / --Sta t -e Work -Done <br />PUMP. REPAIR.*J // state Work Done <br />LIN,YS PIT PRI'V'Y <br />C S L/SEEPAGE PIT OTHER. <br />Dia. of.Well Excava <br />Iiia. of Well Casing <br />Gauge of Casing — <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />R <br />I <br />,,DFAtRUCTION OF WELL: Well Diameter '' Approximate Depth .; K <br />Describe Material and Procedure <br />I hereby agree to comply with all laws and regulations of the Sari 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 of the well notify them isefore putting the well in use. The above " <br />information raj true to he bes y�c3wledge and belief. <br />1✓ /� ! , w <br />SIGNED <br />T 'E I <br />TITLE <br />SE SI: <br />J <br />2. .ICAiION ACCEPTED BY .. DATE <br />ADDITIONAL COMMENT'S <br />PHAS II GitOUT INSPECTia PRASE 111 FINAL I <br />iN5 DATE INSPECTION BY &I-/-, D. <br />t . <br />CA3.L FOB A GRO SI'ECTIOId P tii3R TO GiinU"i 7JtiG AND FIXQ INSPECTION. <br />E N 1426 <br />E!C!tION <br />K /71,t as <br />a <br />