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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.,; -397 <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 and' the Rules and <br /> Regulations of the San Joaquin Local Health District. <br /> ��/ 3R.}. <br /> JOB ADDRESS/LOCATION _ _ "i C ORNER .OP SKZFE`_ AND Will°ALLEN„` ^_ CENSUS TRACT �o S'.- 1lvG--d j <br /> Owner's Name C10 MARION VAN VLIET- (DIDDESTO LAND DEVELOPERS) Phone838-7788 <br /> Address 15151 BRENNAN .ROAD ESGALON City ESCALON <br /> Contractor's Name T.D. SUTTON APTD S0 T License .j 279010 Phone 838-2207 <br /> TYPE OF WORK (Check): NEW WELL /J DEEPEN /7 RECONDITION/_ DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /X/ TURN AMP TOWT RDS DISURARGE STAND PIPE " <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ~� <br /> Domestic/private Drilled Ilia. of Well- Casing + � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal <br /> Other Rotary Type of Grout C <br /> Other Other Information 4�3 <br /> PUMP INSTALLATION: Contractor <br /> If Type of Pump H..P. <br /> r� <br /> C PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR: <br /> / / Stale Work-Dane �_Y� - <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />