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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .OF.7O4,ICE US_E. 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 '� -!�.j� <br /> (Complete In Triplicate) <br /> r Application is herebypade to the San Joaquin Local Health District for a permit to const'r'uct <br /> and/or install the wok herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No, i862 and the Rules and Regulationa o€ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION II11 11225 F, Hi hway 26 CENSUS TRACT <br /> Owner's Name � CEMRYLANE TRAILOA COURT Phone <br /> Address ' Same as above City ' Stodkton <br /> Contractor's Name 1� LINDEN SERVICE PUMPS License #Appli_e_d Phone 887-369-8 <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN/ / RECONDITION I I DESTRUCTION /? <br /> Unknown PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: 11SEPTIC TANK SEWER LINES PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> il[ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Industrial X _ Cable Tool Dia. of Well Excavation <br /> _ Domestic/private _ Drilled Dia. of Well. Casing <br /> l Domestic/public!, Driven Gauge of Casing <br /> Irrigation � Gravel Pack Depth of Grout Seal <br /> 4 Other Rotary Type of Grout <br /> F I�' Other Other Information <br /> PUMP INSTALLATION: Contractor LINDEN SERVICE PUMPS <br /> ' Type of Pump Turbine H.P. 2 <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> ' PUMP REPAIR: State Work Done <br /> L <br /> DF9TRUCTION 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 /> 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 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 -'_ ( TITLE PARTNER <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> " n FOR DEPARTMENT USE ONLY <br /> PHASE- I TE S <br /> APPLICATION ACCEP ED ;BY 1. <br /> ADDITIONAL COMMENTS: I�. <br /> PHASE .It GROUT IN PECTION P SE INSPECTION <br /> INSPECTION BY �� DATE INSPECTION BY DATE +_�2Zr� <br /> ,-CALL FORA GROUT- IS CTION PRIOR TO GROUTING AND ,FINAL INSP <br /> E 11 1426 �� <br />