Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75---,r�1�f4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM..DATE '.ISSU'ED ' Date Issued22 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> A-6•cl 2*s--r3 o.:-.3 <br /> JOB ADDRESS/LOCATION Carrolton` Roadbetween Mello & River Road CENSUS TRACT - <br /> Owner'skI <br /> Name ,- John Zuidervaart Phone 599 <br /> -30 <br /> 71 <br /> 'Address, Avenue. Ripor�� Cal. <br /> _ � City <br /> Contractor's Name, Hennings Bros . Drilling CO3 , Inc. 290813 522-1031- <br /> License # . . ' Phone <br /> 2500 75SEum e. o ,_ o <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION 17 DESTRUCTION f-j <br /> PUMP INSTALLATION PUMP--REPAIR -/ PUMP REPLACEMENT. f7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 109 SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 0 Industria]. Cable Tool Dia.. of Well Excavation 11r� <br /> X Domestic/private �� Drilled Dia. of Well Casing <br /> 6-)18 <br /> Domestic/public Driven Gauge of Casing a <br /> , Irrigation Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection . 7 Rotary Type of Grout BeUonite <br /> Disposal + Other Other Information a y own. . . <br /> Geophysical Surface Seal Installed By: rie r <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done t <br /> `PUMP'REPAIR: ��f i' /% State Work Done' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -- Describe Materialland 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 "construttion. 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 XNSPECTION, <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - HENN14GS BROS. DRILLING =. , INC-BYITLE <br /> (DRAW PLOT PLAN ON REV SE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Irl <br /> E APPLICATION' ACCEPTED BY AV ADATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAM IIZFYINAL INSPECTION <br /> IN BY DATE INSPECTION BY DATE <br /> E 'R 1426 Rpv. 1-74 � h/75 .2M_ <br />