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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: �� 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (205) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /3=7-76 <br /> (Completed 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 Jcaquin Local Health District. <br /> JOB ADDRESS/LOCATION 142)? z T,njs� .'ve _Ripon Qa. CENSUS TRACT <br /> Uwner's Name mil], Slikkar ,)ne <br /> Address 14222 E. ],Oise :1ve City Ripon <br /> Contractor's Name __iz.,,1 tc+- G_ !,Tnaek La7.4D_ License $ 200794 Phone 948-8817 <br /> TYPE OF WORK (Check): NEW WELL /_/ DEEPEN /_7 RECONDITION /—/ DESTRUCTION J 7 <br /> PUMF INSTALLATION /—/--PUMP REPAIR /—/—PUMP R3PLACEI1E9T )T - <br /> Other / / <br /> DISTANCE 2'O NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC MH,�IESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION3 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ y _ Domestic/private Drilled Dia. of Well Casing 1„ <br /> Domestic/public _ Driven Gauge of Casing <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor ',:alter G. Noack E: Son <br /> Type of Pump _ Sub:aersible H.P. d <br /> PUMP REPLACEMENT: f) State Work Done Installed new pump <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to c:mply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction.. Within FIYrERN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RF20RT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SSGNED ''-L 44 ' T_ITLE <br /> TT ''�� :77 DRAW P= rLAN ON REVERSE SIDET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A_9PLICATION ACCEPTED BY ��' / 'j-/T% DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I F Ai INSPECTI <br /> INSPECTION BY DATE I14SPECTION BY DATE <br /> �76 2N <br /> E H 1426 Rev. 1-74 <br />