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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ' j1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21_,;a6rc1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �.�-3 2 <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- Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6401 N. LeRoy Road and 2,200' W. of 1417 .h Ripon Road CENSUS TRACT <br /> Owner's Name Dick Boersma -- Phone <br /> Address 25322 E. Rwy. 120, Ripon, Calif. 95366 r" City <br /> r y l <br /> Contractor's NamePurvianceDrillers,P.O.Box 64,T indene Calif. License # 240-107 Phone ' 933.-�C$ <br /> t_ A <br /> TYPE OF WORK (Check) : NEW WELL "/x/ ` DEEPEN'�I��—RECONDITION / � DESTRUCTION / T_-_ <br /> PUMP INSTALLATION / I PUMP REPAIR/ / PUMP REPLACEMENT 17 C <br /> Other J-7 <br /> 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK 64ot SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> _INTENDED USE ; TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 1.2" <br /> Domestic/private Drilled Dia. of Well Casing 12" <br /> Domestic/public Driven Gauge of Casing 10 <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout °F <br /> Disposal-" Other Other Information ' <br /> Geophysical Surface Seal Installed By: X <br /> PUMP INSTALLATION: Contractor , <br /> " Type of Pump H.P. Sl - <br /> PUMP REPLACEMENT: ' / / ' State Work Done <br /> PUMP-..REPAIR: / -$tate Work,Done ._ <br /> /' - <br /> t <br /> DESTRUCTION OF-WELL: Well Diameter _ Approximate Depth <br /> -Describe'Materials and Procedure _T _- s, <br /> I Hereby agree to comply with all laws and regulations of the San,Joaquin Local Health District" { <br /> ark the Stati of California pertaining to or regulating well'-construction. Within FIFTEEN' DA* <br /> atter completion of my work on a new well, I will furnish the SanaJoaquin 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 WILI' CALL FOR A GROUT INSPECTION <br /> i PRIOR TO GROUTIN A FINAL .INSPECTION. <br /> SIGNED TITLE Partner <br /> - ,(DRAW P I T PLAN 'ON RE ERSE SIDE) <br /> 4. FOR DEPARTMENT. USE ONLY <br /> PHASE l <br /> APPLICATION ACCEPTED BY " " DATE l �` <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0 NS ECTION PHAS�2 III/FmAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 1012 <br /> r <br /> 3/76H 1426 Rev. 1 -74 <br /> _ <br />