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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 36�Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 7_ S-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/LOCATION -16151. Steinegul Rd. Escalon CENSUS TRACT <br /> Owner's Name Richard Myers Phone 838-7511 <br /> Address P. d.. Box 116 <br /> City Ascalon <br /> Contractor's Name T. B. Sutton & Son <br /> License # 279010Phone 838-2207 <br /> TYPE OF WORK (Check) : NEW WELL /�� DEEPEN_!_% RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / J PUMP REPAIR /_/ PUMP REPLACEMENT / <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 /> 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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /g% State Work Done Remove 1 h. p. pump-repair replace. <br /> PUMP REPAIR: / / State Work Done - <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 . .J. TITLE Partner <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION E I i. �INAL �DATPE <br /> CT ON <br /> INSPECTION BY DATE INSPEC - S- -' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />