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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOt. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued C.] <br /> (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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 11225 E. Highway 26 CENSUS TRACT <br /> Owner's Name CHMRYLANE TRAILOR COURT Phone <br /> Address Same as above City Stockton - <br /> Contractor's Name LINDEN SERVICE PUMPS License #Applied Phone 887-3698 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> Unknown PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Jx� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> IN'T'ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial _ X _ Cable Tool Dia. of Well Excavation <br /> X_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor LINDEN SERVICE PUMPS <br /> Type of Pump Turbine H.P. 2 <br /> _ c <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION 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 /> 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 <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 \��� ((l r� '�',i_�:��`-�< TITLE PARTNER <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT IN PECTION %PSEWL��WINSPECTION <br /> INSPECTION BY DATE INSPECTION BDATECALL I'OR -A GROUT NS iCTION PRIOR TO GROUTING AND FINAL INSr /-7 <br />