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Zs- <br /> R ,-�w ti SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�;V- 6L l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby spade 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 13101 3,Highway 99 Ripon, Calif. CENSUS TRACT <br /> Owner's Name <br /> Pete Peros Phone 823-6995 <br /> Address 20782 S.Highway 99 Ripon, California on Ri <br /> City P <br /> Contractor's Name A•Hageman & Son License # 22289$ Phone 599-3287 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / J RECONDITION /_/ DESTRUCTION _� <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /-7 <br /> Other — <br /> DISTANCE TO. NEAREST: SEPTIC TANK lea SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Z Cable Tool Dia. of Well Excavation <br /> f <br /> Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -Irrigation Gravel Gravel Pack Depth of Grout Seal 5 O <br /> Other Rotary Type of Grout Caw C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Corder Drilling Co. <br /> Type of Pump mmers a H.P. 11 <br /> PUMP REPLACEMENT: / / State Work Done <br /> F PUMP UPAIR: / / State Work Done <br /> I DFCTRUCTION OF WELL: Well Diameter Approximate DepthZO <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sari 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 /> t information is true to the best of my knowledge and belief. <br /> e SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPAR XNT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED-BY.-Y'}r� /3 , DATE <br /> ADDITIONAL COQ T <br /> P I OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION`BY DATE .- 7i/'— INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GRQ ING AND FINAL INSPECTION. <br /> E H 1426--- _ 5/731M <br />