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SA" 'OAQUIN LOCAL HEALTH DISTRICT <br /> O—E OFFICE USE: 1601 B- Hazelton Ave. , Stockton, Cali: . <br /> 8 <br /> Telephone: (209) 466-6781 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -z2j.��-0 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Cj <br /> (Complete In Triplicate) <br /> application is hereby made to 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 Joaqu <br /> ,ounty Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION West side Mohler Rd. & j mile South of Test Ripon CENSUS TRACT <br /> honer s Name Raymond Mohler _ <br /> • Phone <br /> lddress 25185 S. Mohler Road Ripon, Calif. 95366 City <br /> ;ontractor's Name Purviance Dri'16rs,P.O.Box 64jinde Cabif. License 4 2401.07 Phone-931-4468 <br /> 95236 <br /> :YPE OF WORK (Check) : NEW WELL )E_1 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ —PUMP PUMP REPAIR /—/—PUMP PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> )ISTANCE TO NEAREST: SEPTIC TANK >300 SEWER 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 W1 <br /> _ Domestic/private Drilled Dia, of Well Casing6 <br /> Domestic/public Driver, Gauge of Casing 3i.7 " Plate <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ?UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> )ESTRUCTION 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 <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 /> ?RIOR TO GROUTINGD A FINAL INSPECTION. <br /> SIGNED `j 2Yti c( TITLE Partner <br /> 64 11ZL (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3o <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE /s/ i- INSPECTION BY DATE Jnr"1y,1�/ %— - <br /> E H 1426 Rvv. 1-74 "' 75 2M <br />