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l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 41- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS„=�3 <br /> (Complete In Triplicate) <br /> is hereby made to the San Joaquin Local Health District for a permit twfthnSan construct <br /> uiv <br /> Application Y <br /> and/or install the work herein described. This application is made in compliance <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 20600 S SUTLIFF RD <br /> CENSUS TRACT <br /> 838-7464 <br /> Own'er's Name I��ERLYN STEARMAN <br /> Phone <br /> Address SAME <br /> City ESOALOS; <br /> 4�T,D, SU79010 Phone 838-2207 <br /> Contractor's Name SUTTON ON A14D SON License i <br /> � <br /> TYPE OF WORK. (Check) : NEW WELL /� DEEPEN I I RECONDITION DESTRUCTION /-7 ' <br /> k PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /XT <br /> Other / / <br /> WISTANCE. TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> •INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled f"< Dia. of. Well Casing <br /> Domestic/private Gauge of Casing <br /> Domestic/public Driven F • } <br /> iGravel Pack Depth -of Grout Seal <br /> irrigation <br /> _ Other Rotary Type of Grout <br /> Other __-,Other Information. <br /> PUMP INSTALLATION: Contractor. H.P. <br /> .7-7-7�° - -� 'TYPe of Pump <br /> ., R .. • , r. .. I�l�•10VE �II.P. JET A1'IB INSTALL 1H.P. SUB <br /> PUMP REPLACEMENT-. '-, / 4 State Work Done <br /> PUMP-REPAIR: - %/' State:Work Done <br /> ' Approximate Depth <br /> „DESTRUCTION OF WELL: Well Diameter _ <br /> Describe Material and Procedure <br /> to <br /> comply with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree P Y <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after comp <br /> om letion of my work on a new well, I will furnish the San Joaquin Loca1e•HealehaDistrict a <br /> WELL DRILLERS REPORT. of the well and notify them before putting the well in u P <br /> information is tr to the be . of my knowledge and belief. <br /> TITLE PARTNER <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `� DATE �� <br /> APPLICATION ACCEPTED BY4 <br /> ADDITIONAL COMMENTS: PHASE I AL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE �-Z -7`� <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72. 114 Z7 <br /> E R 1426 -- <br />