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SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> FO F. OFFICE USr:• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PMPERMIT Permit No. 7/-3 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE -ISSUED Date Issued 4L-2-z_-2j I <br /> (Complete In Triplicate) <br /> Application is hereby rude to the, San Joaquin i� a1isalth madeinra permit comp�.iaz�cetw�.:thnSanuct <br /> Joaqu�.in <br /> and/or install the work herein described. application <br /> County Ordinance -No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION 31249 E CSS RD <br /> CENSUS TRACT <br /> Owner s Name <br /> OMER IHRIG Phone 838--2870 <br /> City ESCALON <br /> Address SA1�ZE <br /> Contractor's Name T(,Dr SUTTON AND SON <br /> License fir: _?7901 0 Phone 838-220 <br />� y _ _ <br /> TYPE OF WORK (Check) : NEW WELL`w/=EI; ;DEE�'EN `I_PUMPEREPAIR � ' PUMPEREPLACEMEN_ /_T <br /> PUMP INSTALLATION / / Y•F . .. <br /> other/ . . r, <br /> DISTANCE TO NEAREST: SEPTIC TiudK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> JG <br /> _ DED .USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTEND. - <br /> Industrial` . Cable Tool Dia. of Well Excavation <br /> ! Domestic/private ^► Drilled Dia. of Well Casing <br /> Domestic/public. <br /> Driven Gauge.,of Casing <br /> y <br /> I ' Gravel Pack Dep.h cif Grout Seal <br /> rri <br /> k gation • <br /> i�Othex Rotary Type of Grout <br /> - <br /> Other Other"Information ' <br /> i <br /> i - PUMP INSTALLATION: Contractor H.P. . <br /> TYPe of Pump <br /> PUMP REPLACL11ENT: / / State Work Done <br /> State Work Dane RAISE PUMP AND BLOW FOREIGN MATERIAL OU' <br /> PtrMP UPAIR: �/ OF. JET <br /> Approximate Depth <br /> pFgTRUCTION OF WELL: ;Well Diameter <br /> Describe Material and Procedure <br /> ict <br /> . <br /> I hereby agree tvco�np7y with all= laws and regulations of the San Joaquin Local Health Distr <br /> and the State of California pertaining to or regulating raell''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. Theabove <br /> information i true to,-� a best of my knowledge and belief. <br /> { TITLE PARTNER <br /> �t SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' F DEPARTMENT USE ONLY <br /> PHASE I .� ATE <br /> APJLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS �. P II AL INSPECTION <br /> PHASE II GROUT INSPECTION INSP ION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />