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i <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE'OFF1re' USE: 1601 E. Hazelton Ave. , Stockton, C-glif.` <br /> Telephone: (209) 466-•6781 <br /> APPLICATION-FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Y /THISIPERMIT. EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued . _/i� 7 y <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 X � �� p c _ - �� CENSUS TRACT <br /> Owner's Name Simon Weststeyn Phone 599-3$79 <br /> Address 23309 S! Jacktone Rd.. City Ripon <br /> t <br /> Contractor's Name- Hennirgs, Bros. Drilling Co. <br /> Inc. License ff 290813 Phone 522-1031 <br /> 25UD W. humole Rd, Mocto -- <br /> i• <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other --- <br /> DISTANCE TO NEAREST: SEPTIC TANK lop SEWER LINES PIT PRIVY # <br /> SEWAGE DISPOSAL FIELD 11D, CESSPOOL/SEEPAGE PIT OTHER <br /> 1� PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> d <br /> Industrial Cable Tool Dia. of Well Excavation 1211 <br /> Domestic/private Drilled Dia. of Well Casing plastic <br />_- -- Ddmesticublic _�-- <br /> X y� /pIrrigation X ' Gravel Pack Depth of Grout Seal ' <br /> Cathoaic. Protection Rotary Type ,of Grout <br /> V <br />-Disposal., Other Other Information - <br /> Geophysical Surface Seal Installed By: _moi 1l er <br /> PUMP INSTALLATION: Contractor <br /> Type of; Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> f <br /> DESTRUCTION 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 we11•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 /> information is true to the-best of my knowledge and belief_. I WILL CALL FOR A GROUT INSPECT <br /> PRIOR TO GROUEING AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT' FLAN 'ON REVERSE SIDE) " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY min' DATE <br /> ADDITIONAL COMMENTS: NA uxigcaw <br /> PHASE II GROUT INSPECTION PHAS I I/ AL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE D ..yJ­"Z <br /> E H 1426 Rev. 1-74 <br />