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r t <br /> ' ,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE­OFFICE USE: /,,l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _Zf O k1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z__aa_ 7 <br /> (Complete In Triplicate) <br /> Application is hereby made t6 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 /> JOB ADDRESS/LOCATION .2 Nii.�West North Ripon Rd. & Mi. South Santos RdENSUS TRACT <br /> Phone <br /> Owners Name <br /> W. E. Al-ldrin ' j <br /> Address 22877 Horth Ripon Road, Ripon, Cal if."-95366 City <br /> Contractor's Name Furviance D r i1].ers P.O.Eox 64 T�inden Calif. License # 24,:0=407Phone ;93TZ4468 <br /> - 1 i <br />- -T-Y-PE:OF-,WORK•,(Check):= NEW WELL %/:DEEREN=/- /RECONDITION'=/ Y DESTRUCTION <br /> PUMP INSTALLATION /x/ PUMP REPAIR / / PUMP REPLACEMENT IT <br /> Other V07 r <br /> j � I <br /> DISTANCE TO NEAREST.: SEPTIC TANKSEWER LINES PIT PRIVY <br /> �. SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -- •' <br /> _PROP.ERTY':I�INE_-_PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �1 <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .( x Cable Tool Dia. of Well Excavation 't211 <br /> Domestic/private Drilled Dia. of Well Casing :1.2t1 <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary fType of Grout <br /> Disposal Other Other Information ' <br /> Geophysical �Surface, Seal Installed By: <br /> PUMP INSTALLATION: Contractor Furvi-ance_Dril" <br /> Lers Type-.6f Pump Turbine H.P. 20 <br /> PUMP REPLACEMENT: / / `State Work Done <br /> PUMP .REPAIR: / State Work Done77- - <br /> � '�- � ro <br /> DESTRUCTION OF WELL: WellDiameter � ° ' Appximate Depth <br /> Describe Material and#Procedure <br /> 4 ' <br /> I •hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districts' <br /> and the State of California }pertaining to or regulating well construction. Within FIFTEEN DAY�,� <br /> a�';ter completion of my work .on a new well, 1. 'ill furnish the San Joaquin Local Health District <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 OPTI FINAL INSPECTION, TITLE ° j— <br /> i SIGNED ,• y j; ' <br /> I]RAW PI T PLAN ON, REVERSE SIDE <br /> ss FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> { APPLICATION ACCEPTED BY , <br /> ADDITIONAL COMMENTS: , I PHAS I/F INSPECT N <br /> r PHASE II OUT INSPECTION <br /> 014 <br /> INSPECTION BY DATE INSPECTION BY DATEI <br /> f� 3/76 2M <br /> E H 1426 Rev. 1-74 <br />