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r' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E.. Hazelton"Ave. , Stockton, Calif. <br /> E 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 Z /o,,7S <br /> (Complete In Triplicate) <br /> j 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 /> I County Ordinance No. '1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4 <br /> JOB ADDRESS/LOCATION 2633 : E, JONES' RD CENSUS TRACT <br /> Owner's Name ARTHUR ADRIAN _ Phone 838-2671 <br /> Address SAME t City ESOALON <br /> Contractor's Name T.D.. SUTTON AND SON License # 2.79010 Phone 838-2207 <br /> �...._.�......��:.-_ [� 'xe. _mak <br /> TYPE OF WORK (Check) NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION /_7 q. m <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMA' REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation �- <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ,1 Gravel Pack Depth of Grout Seal f� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION.." Contractor <br /> Type of Pump <br /> H.P. , <br /> PUMP REPLACEMENT.: /X/, State Work Done REMOVE j, H.P. JET REPLACE WITH 72 H.P. 9SUB <br /> #- PUMP REPAIR: °/771- 5ta-te"W6rk- Done <br /> ESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure t - <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.Distriet 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 /> G <br /> 1 SIGNED TITLE PARTNER <br /> E (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D ARTMENT USE ONLY <br /> ' PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I1 GROUT INSPECTION PHAS I 1 F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ..- DATE /--Za'75 <br /> - --- --- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> F. <br />