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41 - 337 SAN JOAQUIN LOCAL HEALTH DISTRICT I1f4/1 DVW <br /> FOR OFFICE USE: g y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I <br /> Telephone: (209) 466-6781 7 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PEMIk Permit No--7J=/d-V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedQ_f(77 <br /> (Complete In Triplicate) <br /> Application is hereby made tol-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 Mari alKontinakis ? Phone 982-4105 <br /> Address 17576I1,ouise Avenue Escalon California City Escalon <br /> Contractor's Name s Porter License !1 �- `' 7 Phone �i'� <br /> T4PE OF WORK (Check) : NEW WELL /.T DEEPEN /-7 RECONDITION Q DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> -DIST-AMCE-TO-NEPMST:" SEPTtt-T&K SEWER LINES/ IT <br /> PRIVY N, <br /> SEWAGE DISP SAL FIELD CE SPOOLEEPAGE PIT ^OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 41,5 PUBLIC DOMESTIC WELL—= <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS fn. <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 /> X Irrigation _ .�s.o- Grave•1 Pack � Depttt"Sf"Gio�Seal <br /> Prote <br /> - ^•Ca[hodic ction Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �— <br /> Type of Pump v f' _H.P•, j <br /> PUMP REPLACEMENT.:>--•v-:/�/-^`S'ta`te•WoYk'Done <br /> ERM •REPAIR: /-7 State Work Done N <br /> I Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4l 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 /> tinformation is true to the bes y knowledge and belief. I WILL CALL FOR A*GROUT INSPkCTION <br /> PRIOR TO GROUTING AND A FIN NS CT <br /> '. SIGNED <br /> (DRA T PLAN ON REVERSE SID 1.1 <br /> FOR DEPARTMENT USE ONLY U� <br /> PHASE I _ �.. 6 . <br /> APPLICATION ACCEPTED-BY"" D TE ! <br /> ADDITIONAL' COMMENTS, G _ aS '� //l�.�r5 <br /> PHAS G OU I _�iCT RASE yI /FINAL_ ,2NSP C <br /> INSPECTION BY DATE E -7 INSPECTION BY 'ATE <br /> {t 177 _. 12M <br /> 1 E H 1426 Rev. 1-7�� / � �� <br />