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—,& SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.20 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No., <br /> k THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/®_z x_73 <br /> (Complete In Triplicate) <br /> Application is hereby trade to the San Joaquin Local Health District for a permit to construct <br /> and/or :install the work herein described. - This application is mads in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dia�rict. <br /> JOB ADDRESS/LOCATION 13152 SOUTH DROGE ROAD <br /> CENSUS TRACT <br /> 4 _ <br /> Owner's Name VERNON FINK Phone 838.-7,952 <br /> Address. SANS City 'ESCkLON <br /> Contr'actor's Name T .D. SUTTON APD SON License # 277010 Phone ' 838-2202 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_/ RECONDITION �/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR% / PUMP REPLACEMENT &7 <br /> .. Other -/% <br /> DISTANCE TO NEAREST: SEPTIC"TANK - a - SEWER LINES PIT PRIVY <br /> e <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toole Dia. of,Well Excavation <br /> I 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done RETIOVE 1 H.P. SUB /INSTALL 7H P STIR <br />--PUMP - 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 `coiistiructiori.f Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District al <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 TITLE PARTNER <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT USE ONLY f <br /> PHASE I `\ <br /> APPLICATION ACCEPTED BY DATE 0--1'x'7,3 <br />�y -ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E TI AL INSPECTION <br /> INSPECTION BY -- -, . DATE INSPECT' OkBY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> :, _E H 1426 _- - . _ _ 5/.73im r 1 <br />