Laserfiche WebLink
e , <br /> it Q SAN JOAQUIN FOCAL HEALTH DISTRICT <br /> FO£�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 /�J <br /> !� THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-,2_.2-0;_ <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> iN <br /> JOE ADDRESS/LOCATION _ 11.23252 So. Olive Ripon, Cal CENSUS TRACT <br /> Owner's Name Arthur Weststeyn Phone 599-3193 <br /> Address 22563 South highland City Ripon, Cal <br /> Contractor's Name Hennings Bros. Drilling Co. , - Inc.- 290813# .290813 phone .522-1031 <br /> 2 00 �rlest Rum � Tal. 95350. <br /> TYPE OF WORK (Check) : [NEW WELL DEEPEN='./� RECONDITION *� DESTRUCTION f_7 <br /> r�PUMP INSTALLATION /�/ PUMP REPAIR'/-7—pump REPLACEMENT 1 <br /> h,Other L-1 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL A, •4 CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 Cable Tool Dia. of Well Excavation 11" <br /> Domestic/private Drilled Dia, of Well Casing e, <br /> Domestic/public TDriven Gauge of Casing <br /> Irrigation II, , Gravel Pack Depth of Grout Seal p rn <br /> Cathodic Pxotection X- Rotary Type of Grout ' R_e_n tp, ate V <br /> Disposal Other _ Other Information Slab by-owner <br /> Geophysical Surface Seal. Installed By: Dj?'iller <br /> iPUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. . <br /> PUMP REPLACEMENT / / State Work Done . <br /> PUMP :REPAIR: y7 l State t.Tork~Dofte <br /> DES-TRUCTION OF WELL: Well. Diameter w Approximate Depth <br /> Describe Material and Procedure <br /> R <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> r 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 ofli the well and notify them before putting.. th•e..wel1. 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 TOU INC AND{ <br /> D !"E(MION. <br /> SIGNETITLE <br /> 1 ! (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHA ; , FOR DEPARTMENT USE ONLY +t t <br /> APPLICATION ACCEPTED BY IT DATE '/ <br /> ADDITIONAL COMMENTS: i= <br /> i PHASE II GROUT INSPECTION P ITWMAL INSPECTION <br /> INSPECTION BY iE DATE. 'INSPECTION B DATE! G .� <br /> E H 1426 -74 �.: <br /> . /�C <br /> Rev. <br /> 1mar <br />