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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .OFVICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�� <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 20234 E. AVENA RD CENSUS TRACT <br /> Owner's Name GUS VANDER MEULEN Phone 838-2606 <br /> Address SAME City ESCALON <br /> Contractor's Name T.D. SUTTON AND SON License #279010 Phone 838-2207 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C <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 .� <br /> Other Rotary - Type of Grout C <br /> Other Other Information (� <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / f State Work Done <br /> FOR REPAIR Akin R .A 1�ND <br /> PUMP REPAIR: /$/ State Work Done REPLACE PUMP <br />,,DESTRUCTION 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 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. <br /> SIGNED TITLEPARTNER <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 �7 <br /> ADDITIONAL COMMENTS: ,/ <br /> PHASE II 42UT INSPECTION P E IIF AL INSPECTION <br /> INSPECTION BY ..-1 DATE INSPECT-IONB ✓ DATE /j -7- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />