Laserfiche WebLink
► " ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP.r5MICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued el <br /> (Complete In Triplicate) <br /> Appliedtion is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 /> 2'7 fc qo S. CFq A4S 4,6. j dam ;• ""-) ; ?sz ---0 fD _a Z . <br /> JOB ADDRESS/LOCATION 5011 East of Chrisman Rd adjacent to southern CENSUS TRACT <br /> boundary of Tracy Defense Depot <br /> Owner's Name Tom Fornasero Phone 209/835-2997 <br /> Address 7681 W Unne RoadCity Tracy, CA <br /> i <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> f TYPE OF WORK (Check) : NEW WELL /7 DEEPEN I? RECONDITION 17 DESTRUCTION f7 <br /> PUMP INSTALLATION /X PUMP REPAIR /� PUMP REPLACEMENT f7 d <br /> Other <br /> I DISTANCE TO NEAREST: SEPTIC TANK 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 Cable Tool Dia. .of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public. _ Driven. _ _.. Gauge. of�Casing <br /> Iririgation 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 /> PUMP INSTALLATION: Contractor <br /> j 'Type of Pump vertigal H.P. 50 <br /> PUMP REPLACEMENT: ET State Work Done <br /> PUMP-'REPAIR: /-T State Work Done <br /> f 2LS TRUCTION 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 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 o€ knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR T.0 A FI INSP IO <br /> k SIGNE : TITLE Presido t <br /> t RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I FT4NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z= `-� <br /> `}1 E H 1426 Rev. 1-74 1-74 2M <br />