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SAN JOAQUIN LOCAL HEALTH DISTRICT yo P��"p�� . " . Z C3FOF OFFICE USE: 1601 E. Hazelton Ave.-, ,Stockton, Calif. <br /> Telephone: (209) 466-6781 ;7-17�O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuecPEC 26 1977 <br /> (Complete In Triplicate) <br /> Application is tereby''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 /> JOS ADDRESS/LOCATION North West Corner Of E. Main St & Manley CENSUS TRACT <br /> a, <br /> Owner's Name City Of Ripon Phone 599 2:108 <br /> Address City Hall City Ripon <br /> Contractor's Name Parrish Inc. License #1005-11 Phone 4663831 <br /> TYPE OF WORK (Check) : NEW ELL /� EPEN /_/ RECONDITION /_ DESTRUCTION / 7 <br /> PU INSTALL ION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Othe <br /> DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES 1UU1 PIT PRIVY none <br /> SEWAGE DISPOSAL FIELD none CESSPOOL/SEEPAGE PIT none OTHER none <br /> O PROPERTY LINE -- PRIVATE DOMESTIC WELL �0 PUBLIC DOMESTIC WELL <br /> INTENDED USE *, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Lb <br /> Domestic/private ,� Drilled Dia. of Well Casing V. <br /> X� Domestic/public Driven Gauge of Casing <br /> Irrigation XX Gravel rack Depth of Grout Seal Neat cement <br /> Cathodic Protection Rotary Type of Grout Ba c emeri <br /> Disposal Other Other Information _ deep <br /> Geophysical Surface Seal Installed B : Parrish Inc. <br /> PUMP INSTALLATION: Contractor Parrish Inc. Or Wafer Noack Pump, Co. <br /> Type of Pump Deep well turbin H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> 1DES•TRUCTION 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 /> linformation is true to the best of my knowledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. k <br /> SIGNED Parrish Inc. By: TITLE President <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4APPLICATION ACCEPTED BY ' DATEAQ , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 4,.,',�a�--INSPECTION B PHAS II/FINAL INSPECT ON ¢. <br /> INSPECTION BY DATE/2�3l�' 7 DATE] <br /> ae <br />