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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E'Or. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued LZ .-7 3 <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/LOCATIONS W CORNER OF RIVER RD. AND BURWOOD RD. CENSUS TRACT - if'?- ZYV -©.3: <br /> Owner's Name ESCALON UNIFIED SCHOOL DISTRICT Phone 838-7073 <br /> a <br /> Address 1 520 E. YOSEMITE AVE. City ESCALON <br /> Contractor's Name T.D. SUTTON AND SON a License # 279010 Phone 838-2.207 <br /> TYPE OF WORK (Check): NEW WELL ',/ / DEEPEN /F / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / ; PIW REPAIR -f / PUMP REPLACEMENT /- � <br /> Other / ., REMOVE-3HF `SUB( OUT"OF SERVICE-WELL`} <br /> o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD '' CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r.` Cable Tool ­ +Dia. of Well Excavation . <br /> Domestic/private - Cable <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing t <br /> Irrigation Gravel Pack: Depth of Grout Seal :• <br /> Other Rotary—.,, Type of Grout ' <br /> A - A ,Other Other Information <br /> PUMP INSTALLATION: Contractor ' 1 rm i <br /> Type of Pump S H.P. <br /> PUMP REPLACEMENT: f / State Work_Doze <br /> PUMP `iEPAIR: f / State Work Done - <br /> .DFgTRUCTION OF ,WELL: Weil 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 /> SIGNEDTITLE PARTNER <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CGI fMNTS: <br /> PHASE II GROUT IN&PECTION E II NAL INSPEC N <br /> INSPECTION BY DATE ECTIO DATE -10. <br /> CALL FOR A GROUT INSPECTION PRIOR TO- GROUTING AND FINAL INSPECTI <br />---a_'E' H 1426 5/731M <br />