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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3_�3 a <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (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 Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .15400 E. Highway 26 ,,,..,.. CENSUS TRACT <br /> Owner's Name FRANK. GjAH=CEINL ----- Phone <br /> Address _1540Q E. HXgrhwu 26 L_, : City Linden <br /> Contractor's Name Iia License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /j RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR j/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PI'S PRIVY <br /> (Unknown SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -Irrigation <br /> INTENDED USE TYPE OF`WEL-L---- _ CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool 1L Dza:• of_Well - Excavation � <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic �r k � - - -- <br /> -/publ is Driven Gauge tof Casing F�z <br /> XX Irrigati-on Gravel Pack Depth e f-Grout,Seal , C <br /> Other Rotary �' ' ' � Type of Grout <br /> Other Other Information <br /> PUi V INSTALLATION: Contractor <br /> Type of Pump Turbine -- ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> i PUMP UPAIR: /XI State Work Done yp er-2 }_feet <br /> PFRTRUCTION 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 /> a <br /> i 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 DRILLE4 REPORT-)of tine well and notify them before putting the well in use. The above <br /> informatio 's tr the best of my knowledge and belief. <br /> SIGNED z 21 TITLE <br /> s (DRAW PLOT PLAN ON REVERSE SID2�} <br /> i FOR fiEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE 3 <br /> ADDITIONAL CO%1MENTS <br /> PHASE ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTIONBY V DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRION; TO GROUTING AND FINAL INSP ON. CD <br /> E H 1426 -5/731M <br />