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L� 1 ` N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160s-E. Hazelton Ave. , Stockton, Ca:�. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /�l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 /> /C7/, 4, <br /> JOB ADDRESS/LOCATION 14999 F T,nisP Ane Ripon Ca. CENSUS TRACT <br /> Owner's Name 'Rill Slikkar Phone <br /> Address 14222 E. Loise rive City Ripon <br /> Contractor's Name tal tPr G_ Nna.ck &. Son License 9 200794 Phone 948-8817 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <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 /> X Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: p <br /> PUMP INSTALLATION: Contractor WnI ter G. Noack & Son <br /> Type of Pump Submersible H.P. <br /> PUMP REPLACEMENT: $x/ 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 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ��AA <br /> SIGNED _;A4&&2r�f!- �, TITLE <br /> t/ DRAW PPLAN ON REVERSE SIDEr— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4/-1- / ( DATE r "- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I F INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3V76 214 <br /> F A 1426 Rov- 7-74 .. - t <br />