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/JI 33� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> FOF OFFICE USE: 91 � <br /> 1601 E. Hazelton Ave. , Stockton, Calif.Telephone; (209) 466-6781 ' T ICATION FOR WELL CONSTRUCTION OR PUMP PERAk Permit No�7_/a z' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> ,I (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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 11150IEast Highway 120 >,: CENSUS TRACT <br /> Owner's Name MariaMontinakis ? Phone 982-4105 <br /> Address 17576ILouise Avenue Escalon California City Escalon <br /> Contractor's Name Porter ^ License `'S 7 Phone 3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL LV/ DEEPEN /_7 RECONDITION /7 DESTRUCTION /-J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> -DISTANCE-TO-NEAREST:—SEPTIC`TANK SEWER LINES/ PIT PRIVY <br /> SEWAGE DISP SAL FIELD CE SPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/7,5 PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (n.# <br /> Industrial Cable Tool Dia. of Well Excavation A/ p <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing. <br /> X Irrigation , „ Gravel Pack • -DepzH'b -Giouf-SeaI <br /> - '^-=" -ca[hodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �— <br /> Type of Pump v �' _H•P• <br /> PUMP REPLACEMENT.:_-- /-/-�S'Lte Work Done ' <br /> DUMP •REPAIR: / / State Work Done N <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> C <br /> 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 a <br /> ' WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> ` information is true to the bes y knowledge and belief. I WILL CALL FOR A GROUT INSP•CTION <br /> PRIOR TO GROUTING AND A FIN 41NSOE&T <br /> SIGNED <br /> �r (DRAW—=T PLAN ON REVERSE SID t <br /> FOR DEPARTMENT USE ONLY _VP <br /> PHASE I ...... y,. - // <br /> 'APPLICATION ACCEPTED-BY DJATE �i <br /> ADDITIONAL" COMMENTS S d SS ✓-�+�rSL�.� <br /> PRA G OU I _SGT '"" � � "CHASE I /FINAL_ ,4NSP C <br /> INSPECTION BY / DATE 6 -7 INSPECTION BY �/ /ATE <br /> E H 1426 Rev. 1-74 / � $� 1/77 2M <br />