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1(i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF" OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3=S3a (� <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> y (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 Joaquin Local, Health Disgrict. <br /> JOB ADDRESS/LOCATION 15400 E Highway 26 CENSUS TRACT <br /> Owner's Name FRANK GIANNECCHTNI Phone <br /> Address 15400 E. Highway 26 City Linden <br /> Contractor's Name - �t~: License # Phone <br /> PE OF WORK (Check) : NEW WELL / /C DEEPEN /_/PRECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION J / PUMP REPAIR —PUMP PUMP REPLACEMENT /-7 <br /> Other / / - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> (Unknown�. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Irriation We`1T)-- + <br /> INTENDED USE TYPE OF-WEL-L-"t_. CONSTRUCTION SPECIFICATIONS G <br /> Industrial XX Cable Tool 1` Dia:—of_Well Excavation <br /> Domestic/private Drilled , Dia. of Well Casing-1, f <br /> Domestic-/public Driven Gauge'(of Casing �'- k = C <br /> XX Irrigation Gravel Pack. Depth of-Grout,1Seal >; C <br /> f Other = Rotary "�� Type of Grout <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -"Turbine- - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t _ , <br /> PUMP 'tEPAIR: /X/ State Work Done _ Lower 2(),-Fleet <br /> _ <br /> { .DFITRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a <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 DRILLE REPOR of the well and notify them before putting ,the well in use. The above <br /> informatio s tr the best of my knowledge and belief. <br /> i <br /> 5 SIGNED TITLE e./ <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I � D <br /> APPLICATION ACCEPTED B w'Z DATE �3 <br /> ADDITIONAL COMMENTS: <br /> PHASE ROUT INSPECTION P SE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPLaON. C D <br /> .E H 1426 '5/731M <br />