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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,A66-6-7$�; <br /> APPLICATION FOR WELL CONSTRUd N:` D yP '�'P RMLT Permit No. �/vP <br /> THIS PERMIT EXPIRES 1 YEAR FROM.;DATE ISSUED�� Date Issued <br /> Tr l i � <br /> (Complete In ,ip irate) l9j3 <br /> Application is hereby made to the San Joaquin Local iH a1th, District for a permit to construct <br /> and/or install the work herein described. This applicati�1s'1'dade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations nf'tt'%SS.,anF bAquin Local Health District. <br /> JOB ADDRESS/LOCATION 21413 S HAROLD AVE. CENSUS TRACT 5 <br /> Owner's Name JAMES VRIELINO Phone 838-2860 <br /> Address SAME City ESCALON ' <br /> Contractor's Name T.D. SUTTON AND SON License # 279010 Phone 838-3207 <br /> TYPE OF WORK (Check) : NEW WELL /-T DEEPEN /_% RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION / / 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 e. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done REMOVE i l h.p. JET REPLACE WITH 12H.P. SUB <br />- PUMP REPAIR: / /` Sfate 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 TITLE PARTNER _ <br /> ( LOT PLAN ON REVERSE SID-E- " <br /> PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II S E ItI/XANAL INSPECTION <br /> INSPECTION BYD 4TV INSPEC N B QDATE -Z3' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . 7/72 1M <br />