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/7I 337 SAN JOAQUIN LOCAL HEALTH DISTRICTYw' i <br /> F06 OFFICE USE• fg y 1601 E. Hazelton Ave. , Stockton, Calif. -7 Y inw+M 4 <br /> c I� 1. Telephone: (209) 466-6781 "' ' Ti ' <br /> AY PLICATION FOR WELL CONSTRUCTION OR PUMP PER99t Permit No,77_/a_;2�5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9/6 7 7 <br /> l (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 Maria'Montinakis Phone 982-4105 <br /> Address 17576ILouise Avenue Escalon California City Escalon <br /> I � I <br /> Contractor's Name •rA6 Porter Ahq License H L`'S7Phonegi&�,661 <br /> TI'PE OF WORK (Check) : NEW WELL /3/ DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> -DIST-ANCE-TO•NEAREST:—SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD d SPOOL/SEEPAGE PIT ^OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL—= <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (n. <br /> Industrial Cable Tool Dia. of Well Excavation /� p <br /> Domestic/private Drilled Dia, of Well Casing _ <br /> Domestic/public - Driven Gauge of Casing_ -- <br /> _ C Irrigation �„_...Gravel--Pack-=� Depttt'3f"Grou'r�Seal <br /> - ­�`Ca'tffoaic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed II <br /> PUMP INSTALLATION: Contractor -` V, 71 <br /> Type of Pump v j _H, <br /> PUMP REPLACEM[:NT.:.- -.-¢-/-,S't'ate Work Done <br /> HIM -REPAIR: / / State Work Done N <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 the. well 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 NS CT - <br /> SIGNEDTITLE1 <br /> (DRA T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D TE— T"v �i <br /> 'APPLICATION ACCEPTLD-EY ,(A <br /> 1INSPECTION <br /> ADDITIONAL" COMMENTSy L SS -AIFINALPHA G 0 'PHASE I /FINAL_ ,BNSP <br /> INSPECTION BY ,// ATE ,/-Z -7 EY DATE 6 '7 / �F---- -- <br /> / IIj7 2M IL <br /> E H 1426 Rev. 1-74 l /�� $� � <br />