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-° SAN JOAQUIN LOCAL HEALTH DISTRICT *' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/1_,7 1 <br /> (Complete In Triplicate) <br /> Application is hereby made to the' San Joaquin Local Health District for a permit to constr-u¢t� <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 22965 Craig Rd., Escalon CENSUS TRACT <br /> + Jahn Fre eha Phone 838-2570. <br /> Owners Name , <br /> Address <br /> 22956 Craig Rd:° city Escalon <br /> Contractors Name. <br /> T-._ D. Sutton &, Son License # 279010 Phone 8382207' ' <br /> TYPE OF WORK (Check): NEW WELL /_T' DEEPEN /-7/ RECONDITION /_� DESTRUCTION /T <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� <br /> Other <br /> 4 <br /> f DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT - - OTHER <br /> CONSTRUCTION SPECIFICATIONS. <br /> 9 INTENDED USE " S TYPE OF WELL <br /> }� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled t Dia. of Well. Casing <br /> Domestic/public Driven ,[f s Gauge of CasingCIS <br /> Irrigation Gravel Pack ! Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other / Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> l Type of Pump ;' <br /> PUMP REPLACEMENT: / . / State Work Done # <br /> State Work Done" Replac_e. �h ~`p <br /> sub:pump$m' <br /> �f 2E:REPAIR / <br /> DESTRUCTION OF WELL:' Well Diameter Approximate -Depth <br /> Describe Material and Procedure_ <br /> I hereby agree do comply^with' all.�lar.is; 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 furnish the San Joaquin Local Health District a <br /> after completion of my.work on a new well, I wil <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. %,The above- <br /> information is ue to the belst of My knowledge and belief. t, <br /> TITLE Partner <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRD SP CTION PHASE-III/FINAL INSPECTION <br /> ! ' DATE INSPECTION BY �,�e. <br /> IDATE <br /> INSPECTION BY r <br /> V,, CALL,FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _ 7172 1M <br /> E H 1426 <br /> y <br />