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s Y i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT V � <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZLZ.,,2Z`— <br /> $�, THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued -0 ? <br /> (Complete In Triplicate) / <br /> Application is here mAde tot 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 Rulee and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2287/ Noah Ripon- Road CENSUS TRACT <br /> Owner's' Name John Boesch Phone ' <br /> Address 22874 North Ri on Road Ri on CaTif./ City., <br /> Contractor's Name Pury lance Ari�-�.ers P.O.Box 6 T,indeQ�Ca7.:if. License # 240107 Phone - 931 68 <br /> 952 <br /> TYPE OF WORK (Check)Ir � � - -�--��x --- <br /> NEW WELT; / —DEEPEN�/ ":R C� TId14 DESTRUCTION J7 <br /> PUMP INSTALLATION /X/ .PUMP REPAIR'-/_7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3601 SEWER LINES 36o, • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 360' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL A '.-CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable -Tool-- Dia. of Well Excavation 12" <br /> Domestic/private Drilled Dia. of Well Casing Z2" <br /> Domestic/public Driven Gauge of Casing 10 <br /> Irrigation ;i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <i Rotary Type of Grout <br /> Disposal s Other Other Information <br /> Geophysical. � Surface S <br /> _ ea1 Installed By: <br /> PUMP INSTALLATIONa .,y. Contractor - - <br />_ "' ;� `�Purvice"D <br /> aiar3.1 �ers <br /> 1Tyge .of; Pump Subr�ersib H..P. - <br /> 20 <br /> PUMP REPLACEMENT: . ' � /—/ "State <br /> � � �� <br /> , <br /> / / State Work Done <br /> PUMP '.REPAIR; <br />. � / / State •Work Done . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> - <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,besi-of. my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING`AN FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> + (DRAW PLOT .PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE , D <br /> ADDITIONAL COMMENTS: I <br /> PHASE I GROUT INSPECTION PHASE klIlFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1 /�Kqo <br />