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�,.V. .ISO � SAN JOA UIN LOCAL HEALTH - - -�- <br /> Q DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl_, 7,5W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (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 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 /> : <br /> :JOB ADDRESS/.LOCATION... 261.65 E. .River Road CENSUS TRACT <br /> Avner f s Name `T.,W e 'I�NRPHY . <br /> Phone 838-7598 <br /> Address' 16r157FISK' AVE' � City ESCALON <br /> a <br /> Contractor's. Name T.-B. SUTTOE AND 8011 � License # 279010 Phone 8382207 <br /> TYPE.DF WORD (Check):J EW_ \WELL- /�'R DEEPEN'4_7 RECO9DITION /� DESTRUCTION T:� <br /> PUN P INSTALLATION /�}tP64 REPAIR C/�%PLiMP REPLACEMENT <br /> Other-1 <br /> rtiV, .- Wit+ I . , <br /> DISTANCE TO NEAREST: ','SEPTIC TANK SEWER LINES PIT PRIVY s <br /> jSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAiGE PIT ! OTHER <br /> 'PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ` INTENDED USE `�1� TYPE OF KhEI ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Weld: Excavation„ <br /> Domestic/private t �r -� <br /> Drilled' Dia. of Xll Casing i~ <br /> Domestic/pubille �A Driven Q Gauge of Casing <br /> ! <br /> Irrigation •A �`a ,�4 Gravel Pack -Depth of Grout Seal <br /> Cathodic"P=otectio'riL;- I`� Rotary ` - =Typ~e"of"�'Grout ' <br /> j Disposal's , r Other _ Other Information. <br /> Geophysical 4 Surface Seal Installed Sy: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: /X/ State Work Done Remove jet pump and install sub pump <br />;. ...per-:REPAIR: <br /> -- <br /> ES.-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> S Describe Material and Procedure ! <br /> j F <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 myknowledge and -belief. I WILL CALL FOR A -GROUT INSPECTION <br /> kPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE PARTNER <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO ARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATION ACCEPTED B € DATE <br /> ADDITIONAL COMMENTS: <br /> PHASP IIa-GROUT;INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY .DATE INSPECTION BY DATE. /�-A <br /> ,, .E H.1426 Rev. 1-74 _ <br /> 1Y 1-74 -2M.-. '. <br />