Laserfiche WebLink
41 , 33� SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOF- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> I - Telephone : (209) 466-6781 7; <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERAft Permit No,.2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued9 7 <br /> (Complete In Triplicate) <br /> Application is hereby made toFthe San Joaquin Local Health District for a permit to construct r <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 111501E st Highway 120 Vit. CENSUS TRACT <br /> Owner's Name Mari atKontinakis � ; 'y Phone 982-4105 <br /> Address 175761 Louise Avenue Escalon California City Escalon <br /> Contractor's Name •� Porter &ide&49License # a-t 7 Phone 3E ,6 <br /> r <br /> TYPE OF WORK (Check) : NEW WELL /3/ DEEPEN '/ / RECONDITION / / DESTRUCTION /- { <br /> PUMP -INSTALLATION 1—/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other — <br /> DIS-T-ANEE-TO-NEAREST:'—SEPT!C-TANK SEWER LINES` PIT PRIVY^ <br /> SEWAGE DISP SAL FIELD &S—POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -a.S'PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - X Domestic/private Drilled Dia, of Well Casing / P <br /> Domestic/public Driven Gauge of Casing_ <br /> X Irrigation - ,Grave=l-P•ack =-i6;�D6i'tt of-Genu Seal <br />° Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: C2W4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- H.P.. - <br /> PUMP REPL.ACEMENT.:�--- /=/ -State Work Done <br /> PUMP REPAIR: / / State Work Done f" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 5 Describe Material and Procedure <br />� I hereby agree to comply with�all laws and regulations of the San Joaquin Local. Health District <br /> land 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 /> tinformation is true to the bes y knowledge and belief. I WILL CALL FOR A GROUT INSP CTION <br /> PRIOR TO GROUTING AND A FIN NS CT <br /> SIGNED TITLE it <br /> f _ (DRAW—=T PLAN ON REVERSE STD ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '_ <br /> APPLICATION ACCEPTED^-BYE"" DTE <br /> ADDITIONAL" COMMENTS y �G a S '� d/ � «SCS' <br /> PHAS GROUT I __ECT_ Nf .--"PHASEI" /FINAL ZNSP C <br /> 7-7 <br /> INSPECTION BY DATE INSPECTION BY a � ATE JA 2-f- <br /> 117.7 <br /> ,/� B -� 1177 .. ' 2M f. <br /> E H 1426 Rev. 1-74 -_ _ <br />