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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. r,._fne <br /> IJU THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7.29-1 y <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 18059 S CA 2BELL RD CENSUS TRACT <br /> Owner's Name MRS, FRED C . FREDELL Phone 833-2731 <br />+ Address . SATS CityESCALON <br /> Contractor's Name . T.D. SUTTON A1TD SOFT License # 279010 Phone 83842207 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / f PUMP REPAIR —PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> k INTENDED USE TYPE OF WELL % 1 a CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia: of Well Excavation <br /> Domestic/private Drilled Dia.' of Well Casing <br /> Domestic/public Driven „r Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> k, Other Rotary •' Type of Grout' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP REPAIR• / State Work Done INSTALL AUTO KIT ON 1HP SUB <br /> „DESTRUCTION 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 /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tpue, to the best of my knowledge and belief.'' <br /> SIGNED TITLE FARTMER <br /> t <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR TMENT USEONLY <br /> . PHASE I <br /> APPLICATION ACCEPTED B L7 Aj— DATE 7 <br /> ( ADDITIONAL COMMENTS i <br /> r PHASE II GROUT INSPECTION PHA5E I INAL INSPECTION <br /> ' INSPECTION BY INSPECTION BY DATE r,Z73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />