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F <br /> -f ` JOAQUIN LOCAL HEALTH DISTRICT <br /> a FW OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> _I(Complete In Triplicate) <br /> Application is hereby made Tto 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 /> .8 miles South of LeRoy <br /> JOB ADDRESS/LOCATION, I miles West on. North Ripon Rd. � CENSUS TRACT �- <br /> Owner's Name Names Travaille Phone <br /> Address _ _ 18888- N. Ripon Rd. City Ripon <br /> Contractor's Name Purviance Drillers + _ License # 240107 Phone887-355 ; <br /> f <br /> TYPE OF WORK (Check): NEW WELL '/X7 DEEPEN, rf RECONDITION /7 DESTRUCTION r i <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other I I <br /> t <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK1ni1UWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD mil 03ESSPOOL/SEEPAGE PIT OTHER �F <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL y, <br /> INTENDED USE -TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool-- Dia. of Well Excavation 1411 <br /> Domestic/private Drilled Dia. of Well Casing 1411 <br /> Domestic/public Driven Gauge of Casing 10gage w <br /> .XX Irrigation Gravel Pack Depth of Grout Seal -T <br /> Cathodic Protection Rotary - Type of Grout .? <br /> Disposal Other Other Information <br /> Geophysical <br /> --. . . - � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> PUMP :REPAIR: / / State Work f4Done- <br /> 411S.2 <br /> one . <br /> 411S•TRUCTION OF WELL: Well Diameter J i Approximate Depth f4 (? 7"6� <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 GROUTING ANDA FINAL INSPECTION. <br /> SIGNED _11TITLE 1p4p"/J?, <br /> (DRAW PLOT .PLAN ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1� 7 <br /> ADDITIONAL COMMENTS: C ir <br /> PHASE II GROUT INSP CTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY DATE -2_7-1 <br /> jt4 E H.. 1426 Rev. 1-74 �4 2M <br />