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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08�OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> 11 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /o-,2S7ct <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 /> J0B ADDRESS/LOCATION 2.0350 Allen Road CENSUS TRACT <br /> Owner's Name Arthur Azevedo Phone 599-4477 <br /> Address Same <br /> City Ripbn. <br /> Contractor's Name T.D. Sutton and Son License # 279010 phOW838-2207 <br /> TYPE OF WORK (Check)i=''NB(1'WELL LST 'DEEPEN /7 *ECONDITION %j DESTRUCTION ] <br /> PUMP INSTALLATION L�PUMP REPAIR /�—Pump �gf,�,f, _ /�'T <br /> Other Remove old P p from o d well and i�s t al -n new well <br /> 18TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -- PROPERTY LINE - PRIVATE DOMBSTIC WALL PUBLIC IC --RLL 0 <br /> INTENDED USE ,TYPE OF WELL CONSTRUCTION BPBCIFICATIONS W <br /> Industrial . <br /> Cable Tool ' Dia. of Well Excavatidh <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -- <br /> -..� Irrigation Gravel Pack Depth of Grout Seal ,R <br /> _ Cathodic Protection--------_----Rothry Type of Grout <br /> ,Disposal Other <br /> Geophysical _ Surface -Sag! Inst41W AV: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L7 State Work Done <br /> PUMP :REPAIR: L7 -stateWork Done <br /> E U_CT_ION OF WELL: Well Diameter (TO BE DON..8 BYE IWE,R) ,\7 , <br /> pproxisa <br /> te,Depth� ,.. <br /> Describe Material and Procedurk <br /> V Kc <br /> I hereby agree to comply :with all laws and regulationd. of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulatlia well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San 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-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDAINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE lo-;?-r- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> E 11 1426 Rev. 1-74 1-74 2M <br />