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/J ("SAN JOAQUIN LOCAL. HEALTH.DISTRZ <br /> FOL OFFICE USE: �' 1'. E. Hazelton Ave. , Stockton, C if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP.PERMIT Permit No. 7K-//8'd / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE VE COPtlev� Issued /a=7-7� <br /> (Complete In Triplicate) - I E <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 ._ 1422�> B. Lois,e Acre Ripon Ca. CENSUS TRACT <br /> Owner's Name —Bill-Sly ktiAr Phone <br /> Address 14222 S. Loise Ave City _Ripon <br /> Contractor's Name License # 200794 Phone -948-8817. <br /> TYPE OF WORK (Check): NEW WELL "/_7 DEEPEN /7 RECONDITION /_T DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR/ / PUMP REPLACEMENT ; <br /> Other j_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE' PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC- DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . \� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> g Domestic/private Drilled Dia. of Well Casing L <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 7 <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed_BY: q <br /> PUMP INSTALLATION: Contractor Walter G. Noack &, Son <br /> Type of Pump Submersible _- H.P. <br /> PUMP REPLACEMENT: - State Work Done Installed new pump <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply 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 FIFTERND&YS: <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' ii' 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 /> SIGNED � � f�T� -- TITLE <br /> D- W- PLAN''ON REVIRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J/107 <br /> APPLICATION <br /> ADDITIONALCOMMBNTS: <br /> PHASE II GROUT INSPECTION P I A/FJKAI,, INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E R 1A26 RAu_ 1 74 <br />