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41 ' 33T SAN JOAQUIN LOCAL HEALTH DISTRICT lU� <br /> FOR OFFICE USE• g F 1601 E. Hazelton Ave. , Stockton, Calif. 7 '1 . <br /> - <br /> Telephone : (209) 466-6781 "� Ti <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERM-* Permit No,�/,l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedez�(7i <br /> ij (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 Jo4qu <br /> County Ordinance No. 1862 and'•the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 11150+tl� East Highway 120 >r CENSUS TRACT <br /> Owner's Name MariatKontinakis ? Phone 982-4105 <br /> Address 175761Louise Avenue Escalon California City Escalon <br /> Contractor's Name Porter License a' S7 Phone -30 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /-J DESTRUCTION /_T <br /> PUMP -INSTALLATION / / PUMP REPAIR /—/—pump REPLACEMENT /7 <br /> Other <br /> -DISTW—E-TO"NEAREST:—SEPTIr' TANK SEWER LINES` PIT PRIVY <br /> AL 4 <br /> SEWAGE DISP SFIELD Wes PIT + OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/--I PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial —K7 Cable Tool Dia. of Well Excavation // <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public - Driven Gauge of Casing. — <br /> X Irrigation ,—,Gravel- Pack=`=�Dgp'tti 6f Tro `SeaI <br /> —Ca'thodic Pr_otection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor t--- a <br /> Type of Pump I H•P.• <br /> PUMP REPLACEMENT.:_- -: /7--/-—Siate Glork Done <br /> RUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth = <br /> m Describe Material and Procedure <br /> II 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the besy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING_AND A FINA a NS CT <br /> SIGNED -�� <br /> (DRA T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY / OF <br /> PHASE I ..�- D TE �T/��/ f71 <br /> 'APPLICATION ACCEPTED BY <br /> ADDITIONAL' COMMENTS V G <br /> OUT I <br /> PHA G "PHASE I /FINAL NSP C <br /> INSPECTION BY DATE Z6 -7 INSPECTION BY /ATE <br />