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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_ 4/// 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued e-14(-;, <br /> i' SDOIF °" v1�:�"G4 (Complete In Triplicate) <br /> Applicatiion"'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 Joaq <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATIONS W CORNER OF RIVER RD. AND BURWOOD RD. CENSUS TRACT z`f7- ZYD <br /> Owner's Name ESCALON UNIFIED SCHOOL DISTRICT Phone 838-7073 <br /> Address 1'520 E YOSEMITE AVE. City ESCALON <br /> Contractor's Name T .D. SUTTON AND SON License N 279010 Phone 838-2207 <br /> TYPE OF WORK (Check): NEW WELL J% DEEPEN '/7 / RECONDITION / / DESTRUCTION /tea <br /> PUMP INSTALLATION / / ; PLI-W REPAIR '/ / PUMP REPLACEMENT /—T <br /> Other /-1 ' REMOVE-3HP -SUB( OUT-07—SERVICE-WELL -" - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1 r CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool � Dia. of Well Excavation <br /> Domestic/privaee ' a4,*ADrilled 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 /> ] j. . Other Other Information <br /> c r r <br /> PUMP INSTALLATION: Contractor 'w 1 r+. i <br /> Type of Pump T Y H.P. <br /> PUMP REPLACEMENT: <br /> State Work-Done L!V� � Gi'-�`' .4:: O� <br /> E <br /> PUMP UPAIR: State Work Done <br /> ;DFqTRUCTION 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 <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 ' AdA Xp }CTITLE PARTNER <br /> �PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I ECTION E EINNAL INSPEC N <br /> INSPECTION BY DATEECTIO <br /> CAT.T. FIR A GRITTY TNCPRCTTIN PRTIR TI. rVAT7TTffiA Alan TPTWAT. TMCDV!`TT T <br />