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IV.? No Ram/' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT "/1- / <br /> FOFx:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.�/!8/ A'kKcv� cel <br /> Telephone; (209) 466-6781 7 "`'� /00 y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-j,_)-U�) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 'West side Mohler Rd, & j mile South of West Ripon , CENSUS TRACT <br /> Owner's NameMohler, Rd. <br /> Phone�! /` � C <br /> Address 22L85 S Mohler Road Ripon, Ca13f City <br /> Contractor's Name Purviance .DriZ-7.ibrs P.O.Box.64 Linde C$lbif, License # 240107 Phoners937-41.68 <br /> 95236 <br /> TYPE OF WORK (Check)-. NEW WELL -A-7 DEEPEN ,/7 -RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR[7 PUMP REPLACEMENT C f 4 <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK >.3,idl>.3,i4SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> 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 7_ <br /> Domestic/private Drilled Dia. of Well Casing 16 q <br /> Domestic/public Driven Gauge of Casing 3A6" Fl te . . .. \l <br /> X Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT j_/ State Work Done <br /> PUMP_REPAIR: / / State Work Done . <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 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 /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGAND A FINAL INSPECTION. <br /> SIGNED 4, TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I `r <br /> APPLICATION ACCEPTED BY DATE 130'117 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION .1 DATE 1 --7 <br /> E H 1426 Rev. 1-74 - d'lt.�/75 2M <br />