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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- OIa1?TCE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (Complete In Triplicate) <br /> Application is hereby made to tine 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. 1$52 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION COX & .Comstock Road.. Linden, Chi CENSUS TRACT ' <br /> Owner's Name FRANK. GIANNECCH114I Phone <br /> Address 1 400 E. Highway 26 City '.atockton„_...._ <br /> � r <br /> Contractor's Name LINDEN SERVICE PUMPS License #Aj?�ed Phone BEZ--, h9A <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / J PUMP REPAIR'/JF/ PUMP REPLACEMENT /- <br /> Other -/ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Unknown SEWAGE '-DISPOSAL`FIELD P CESSPOOL/SEEPAGE PIT OTHER <br /> -.._._ . w•• _ _ _ - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. "of Well Excavation <br /> Domestic/private Drilled Dia. 7of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type'"of Grout - - <br /> Other Other Information ' <br /> PUMP INSTALLATION; Contractor -PURS = <br /> Type of Pump H.P. _3h <br /> 3R�� <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP `tEPAIR: / / State Work Done ;. <br /> .DF,-TRUCTION OF. WELL: Well Diameter Y 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 of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED s <br /> TITLE PAHTHER' - - <br /> t � '” (DRAW PLOT PLAN ON REVERSE .SIDE) <br /> F'OR DEPARTMENT USE.Ok 19 <br /> NLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBYDATE S -3 <br /> ADDITIONAL'COMMENTS: <br /> PHASE II GROUT INSPECTION P I INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON <br /> E H 1426 5/.731m <br />