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' SAN JOAQUIN LOCAL HEALTH DISTRICT r ,; <br /> FOk;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIST PERMIT EXPIRES l YEAR FROM DATE ISSUED .. Date Issued 6l <br /> (Complete In Triplicate) <br /> Application is hereby made to�,the San Joaquin Local Health District for a permit to construct <br /> and/ox,-install the -work herein described. This application is made in compliance with San Joaquin <br /> County Ordnance No. 1862 and3the Rules and Regulations of the San Joaquin Local Health District• <br /> JOB ADDRESS/LOCATION Aig.1i 15 N. RIPON ROAD. - 1 /2 MILE NO. OF CENSUS TRACT <br /> CLINTON: S0. - r <br /> Owner's Name AUGUST KUIPERRS CONST. Phone 599m39�+6 <br /> City RIPON, CALIF. <br /> Address ET , <br /> Contractor's Name N BE . DRILLING CO . _ INC . License # 290813 Phone 545-1185 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION_ / DESTRUCTION / T <br /> PUMP INSTALLATION / / PUMP REPAIR l�I PUMP REPLACEMENT I I C+i <br /> Other / / .� , <br /> t <br /> DISTANCE TO NEAREST: SEPTIC -TANK 9QM SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 8Dt- + CESSPOOL/SEEPAGE PIT OTHER I <br /> PRO P.ERtx-LINE—_.PRIVATE. I 0MESTI-C-W-&LL--- PUBLIC DOMESTIC WELL <br /> INTENDED USE / TYPE OE, WELL f _.�- CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable To 1 ."`/,,.Dia_.--o.f.}-Well Excavation 11 Inches <br /> y Domestic/private - <br /> - D.r.illled- �'Y L-Dia�of;Well Casing <br /> Domestic/pub-lic Driven Gauge of Casing <br /> 160 <br /> Irrigation ,� f X- Gravel Pack "' Depth of Grout Seal 0 Feel; <br /> Cathodic Protection T1 X Rotary -rType.rof Grout Bentonite <br /> -Disposal Other Oflier`Information Slab by-Owner <br /> Geophysical }. ;p ; Surface Seal Installed By <br /> Driller <br /> C' i I tY 1i <br /> PUMP INSTALLATION: Gont or `, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: )tate Work Done <br /> PUMP .REPAIR: / ./ State Work Done i <br /> DESTRUCT <br /> ION OF WELL: Well Diameter , ' Approximate Depth <br /> Describe Material and Procedure' <br /> I hereby agree to comply with all laws and regulattiojfs of the San Joaquin Local Health Distract <br /> and the State of California pertaining..,to or regulating well'donstruction. Within FIFTEEN DAYS <br /> j 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 v <br /> information is true to the-be-s•t of-my-�k�nowledge-and belief. I WILL CALL FOR A GROUT INSPECT <br /> PRIOR TO GROUTING AND A FIN�,1,--IN-S-PECTICJN. . <br /> SIGNED LRILLI G . 0. INC. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> {- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> • • -Y Y.. _ DATE -- <br /> APPLICATION ACCEPTED 'BY_ <br /> ADDITIONAL COMMENTS: <br /> PHAS I Th.-INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE 6- -70 INSPECTION BY / f DATE0/77 2M <br /> -- <br /> �2c�n <br /> F. H 1626 Rev- 1-74 1-74 I - ��^" �" <br />