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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 -d <br /> THIS PERMIT EXPIRES l 'YEAR FROM DATE` I"SSUE'b" "Date Issued <br /> t (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health Distr ct` 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 and the Rules and Regulations of 'the 'Sa.d Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2nd place on TJ side of Escaloh Bellota CENSt s �TRA* CT <br /> as' u ier KU. going <br /> Owner's Name TAM HAGAN <br /> Phone' 8387686 <br /> Address 1.253 SIERRA DRIVECity ESCALON <br /> Contractor's. Name ,.D- SUTTON <br /> License # Phone - - <br /> - AND SON 279010 838-220"7 <br /> wr - _�..,,,.. <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION —PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ' Other / / <br /> t DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable, Tool ` -:Dia., of'" Well Excavation <br /> Domestic/private Drilled Dia: of-Well Casin <br /> Domestic/public Driven{ 8V <br /> Gauge of�,�Casing� <br /> Irrigation Gravel}Pack. i Depih:. d�f• Grout Seal <br /> Other Rotar <br /> ` Y{ Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor I,D, SUf! ON' kkD SON <br /> 0 Type}of. Pump SUB- <br /> H.P. <br /> PUMP REPLACEMENT: ... . <br /> / / State Work Done <br /> .o PUMP REPAfiR. /771 State Ffo`rk Done <br /> ' — t <br /> „pESTRUCTION OF WELL: Well Diameter - �- Approximate Depth <br /> Describe Material and Procedure - , <br /> s <br /> I hereby agree to comply with all .laws and regulations of the San Joaquin Local Health District <br /> Wand the 5tate�-of-California ipertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion ofj' 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 /> ttinformationrue`taXhie �tm_y knowledge and belief. <br /> SIGNED PARTNER <br /> F c n 'TITLE-.� _ <br /> :'.(DRAW`PLOT;-PLAN, ON REVERSE SIDE <br /> `'F`OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BX DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION P S I NAL INSPECTIO <br /> INSPECTION BY ZULDATE INSPECT B DATE -�- <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> 4 <br />