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Q .} JOAQUIN LOCAL `HEALTH DISTRICT <br /> gOE OFFICE USE: 1601'--.,. Hazelton Ave. , Stockton, Calir� <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7va"Z��Lc� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-.2- <br /> (Complete <br /> .2(Complete In Triplicate) A <br /> Application is hereby shade 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 .Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 252 So. Olive Ripon, Cal CENSUS TRACT <br /> Phone 599-3193 <br /> Owner's Name Arthur lleststeyn <br /> Address . <br /> 22563 South Highland City Ripon, Cal <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc. , License # .280813 Phone 522-1031. i <br /> Contr . ' <br /> 2100 West Rumble R oaes _ Ca-L. 95350, . <br /> TYPE OF WORK (Check) *. NEW WELL/7 DEEPEN J_7 RECONDITION /_T DESTRUCTION F7 <br /> PUMP INSTALLATION I PUMP REPAIR-/ PUMP REPLACEMENT f T <br /> I i <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICSMEDO TIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11s� <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/Private Drilled Iiia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection X. Rotary Type of Grout Bentoj.ite <br /> 'Disposal. Other _ -- Other Information ab b owner <br /> Geophysical ' Surface Seal Installed 'B : Driller <br /> PUMP INSTALLATION*. Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / 1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Materfal 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 U ING AND A I'IME ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 .--� <br /> APPLICATION ACCEPTED BY DATE `/ ' � <br /> ADDITIONAL COMMENTS: P TTIIFXNAL INSPI:CTI - <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE/ G ' , <br />