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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP_PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued /a -7-7- <br /> - . (Complete ,In:.Tx-iplicate),- <br /> Application is hereby"made to the San Joaquin Local Health District for a'permit to construct <br /> �. <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> -e CENSUS TRACT <br /> JOB ADDRESS/LOCATION ',�2�_'0- l,ni Se A3e RipOn Ca. - <br /> t __ <br /> Owner's Name Phone <br /> Address 14222 IJ. Loise Ave City Ripon <br /> �pr <br /> Contractorts Name ;� License # 200794 Phone 948-8817 <br /> :�-1 ,G4 Nnaek � SOYL _— <br /> TYPE OF WORK (Check): , <br /> NEW. WELL '/-7 DEEPEN/7 RECONDITION /-7 DESTRUCTION %T <br /> PUMP INSTALLATION / / PUMP.; REPAIR,/_REPAIR_/ /tPUMPYREPLACEMENT�. <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 /> IndustrialCable Tool Dia. of Well Excavation �- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public'M Driven Gauge of Casing } <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtecEion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUI INSTALLATION: "` Contractor -Walter G lOack" c-'SOri <br /> Type of Pump Submergible H.P. <br /> rl <br /> PUMP REPLACEMENT: / State Work Done Installed new pump <br /> PUMP .REPAIR: / / State Work Done <br /> ( <br /> Approximate Depth ;t4 <br /> l DESTRUCTION OF WELL: Well Diameter PP <br /> S 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 FIBTEEN DAYS, <br /> f after completion of my work on a new well, I will furnish the San Joaquin Local Health District-2 <br /> WELL DRILLERS REPORT of the well and.notify them before-put-ting-the .wellTJfCuse The above <br /> ate:.•, <br /> information ia'true to;the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING AND FINAL, INSPECTION, <br /> SIGNED TITLE .a ,.,: .-_-•�� <br /> DRAW: PLAN 'ON HVifIRSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /eI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I F INSPECTI <br /> r INSPECTION BY DATE INSPECTION BY DATE <br /> V76 2*- <br /> E H 1426 Rev. 1-74 <br />