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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F..OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ff S�S4J <br /> 7S- �-, y z to. <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 /> JOB ADDRESS/LOCATION 'ST =<RIP0k.M- AND ,AUSTIN RD. CENSUS TRACT - <br /> Owner's <br /> RACT -Owner's Name KARVIN J. SEAGER Phone 599-7523 <br /> Address MAIN AND WALNUT AVE City • RIPON <br /> Contractor's Name I.D. SU12TON AND SON _ License # 279G10 Phone 838-2207 <br /> TYPE OF WORK (Check) : NEW WELL -/V� DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION 2j/ PUMP REPAIR ,/ / PUMP REPLACEMENT /-T <br /> Other ./7 <br /> DISTANCE TO NEAREST: SEPTIC TLNK / i SEWER LIjES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ;f <br /> PUMP INSTALLATION: Contractor <br /> T.D. SUTTON AND SUN <br /> Type of Pump S11h H.P. I H.P. <br /> PUMP REPLACEMENT. / / State Work Dome <br /> PUMP UPAIR: / f State Work Done <br /> ,DFRTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information, is true to a best of my knowledge and belief. <br /> SIGNED TITLE PARTHER <br /> (DRAW PLOT PLAN ON REVERSE SIDE) f <br /> FOR DEPARTMENT USE ONLY ' <br /> PiiASE I <br /> APPLICATION ACCEPTED BY l DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHOE IIJ INSPECTION <br /> INSPECTION BY DATE INSPE DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />