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41 3�7 SAN JOAQUIN LOCAL HEALTH DISTRICT ~ ' <br /> FOE OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif.-( . 'I <br /> IS = Telephone: (209) 466-6781 a T <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERA* Permit N0,271647' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9-AK7 7 <br /> 1.1 (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 Josquir <br /> County Ordinance No. 1862 and•,the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 111501East Highway 120 > CENSUS TRACT ' <br /> Owner's Name MarialKontinakis � Phone 982-4105 <br /> Address 17576II.ouise Avenue Escalon California City Escalon f <br /> Contractor's Name -JAM Porter � License # L`°5 7 Phone���i'� <br /> TYPE OF WORK (Check) : NEW WELL /77 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /J] <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> -DISMANEE-TO"NEAREST: "SEP1`YC-T0K SEWER LINES` PIT PRIVY 4 <br /> SEWAGE DISP SAL FIELD CE SPOOL/SEEPAGE PIT Y OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/aSrPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestic/private —^c Drilled Dia, of Well Casing <br /> Domestic/public - Driven Gauge of Casing. <br /> X Irrigation � ,�. Grave•1-Packs-�'- Deptri"Sf�Gio"`uE Seal <br /> ----Cathodic Protection Rotary Type of Grout <br /> Disposal Other other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor -- <br /> Type of Pump o ,� r' 074/?_V11 Advok <br /> _H.R.. <br /> PUMP REPLACEMF�7T.:-----:/ /--SCa-te'67ork Done \ <br /> RUMP •REPAIR: / / State Work Done f <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 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 NS Cf - <br /> SIGNED TITLE <br /> (DRA T PLAN ON REVERSE SID l <br /> FOR DEPARTMENT USE ONLY Up <br /> PHASE I _ / <br /> APPLICATION ACCEPTED SY DJgT ` v f7 <br /> ADDITIONAL- COMMENTS L SS 'C- w-,V S '� <br /> PHA G 0 I RASE �I /FINAL NSP C <br /> INSPECTION BY DATE INSPECTION BY / /ATE //-2-f.- <br /> DATE <br /> rr <br />