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SAN JOAQUIN LOCAL HEALTH DISTRICT ^ <br /> ' FORjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74/, _5-/f/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a�2s }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 2'7762 E. Edwards Ave CENSUS TRACT <br /> Owner's Name Ross Marshall phone unlisted <br /> Address Same City Escalon <br /> Contractor's Name T.D. Sut -on and Son License # 279010 phone 838-2207 <br /> w <br /> 1 <br /> TYPE OF.WORK (Check): NEW WELL/—f DEEPEN /_7 RECONDITION /-' DESTRUCTION f-7 <br /> -PUMP TNSTALLATIOH PUMP REPAIR / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHERy <br /> PROPERTYrLINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELI: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �11 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public -- -Driven Gauge of Casing } <br /> Irrigation Gravel Pack Depth of Grout Seal NJ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: ;y <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H..P. r :� <br /> PUMP REPLACEMENT: /g/ State Work Done Remove 2I-IP Sub & Install 2HP„ Sub <br /> PUMP iREPAIR: T - 1 . , ' .r <br /> L State Work Done " - � �' `3 '; '"'" <br /> ES4RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia snit procedure .-.- <br /> I hereby agree to comply with_all .laws� and regulations of the S-An 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 Sari Joaquin Local Health District a <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 o€; tny knowledge and belief. I HILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROU ING AND FTN INSPE CTION, <br /> ✓� <br /> SIGNED - , - TITLE Partner <br /> DRAW PLOT-PLAN ON REVERSE SIDE <br /> Z,�j ^+ cy y . :A L FOR,DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACC�:PT'ED' By } �� <br /> /✓;'�' DATE .6- 5•7� <br /> ADDITIONAL COMMENTS: a . . <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> S^ f <br /> E H 1426--- Rev. 1-74 f...1-7412M <br />