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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �.3 -7,;V e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-_Z-_2- ,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 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION 27648 JONES AVE CENSUS TRACT <br /> Owner's Name NARAGHI FARMS Phone 838-7066 <br /> Address 20001 S DIC HENRY AVE City ESCALON <br /> Contractor's Name 1.D. SUTTON AND SON License # 279010 Phone 838-2207, <br /> N TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_% RECONDITION /_7 DESTRUCTION /_j <br /> PUMP INSTALLATION / / PUMP REPAIR /47,7 PUMP REPLACEMENT /j� <br /> Other /T/ <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'Domestic/public, Driven Gauge of Casing i + <br /> Irrigatfo64 r-- �=Gr-avel Pack Depth of Grout Seal-. ., <br /> Other > Rotary Type of Grout <br /> _T1. Othei Other Information <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> N PUMP REPLACEMENT: X-7 State Work Done RMIOVE 2 HP. JET INSATLL 5 HP. SUB <br /> PUMP"REPAIR7. -r_. 7: ,a ..may./..eStatdYWoik-DoneIf <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 he best of my knowledge and belief. 1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /�— <br /> f ADDITIONAL COMMENTS: ' 7 <br /> PHASE GROUT INSPECT ON P I INAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY / DATE - - - � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . 7/72 1M �� <br />