Laserfiche WebLink
I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORjOFFICE USE: I� 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 77 <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 Joaquii <br /> County Ordinance No. 1862 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> '�'23Zc7 X, G�c�r-c:cf 4- ,�- " �- -253- Z-5-0-07 <br /> j JOB ADDRESS/LOCATION 100• E of Chrlsman; 1/2 Iii. S of Durham Ferry CENSUS TRACT <br /> ' Narchlese Farms <br /> ' Owner's Name Phone 209/835-8271 <br /> I , <br /> -Address ` -631 fiaffery Road City Vernalis, CA <br /> r 182 295-4332 <br /> Contractor's Name Western Well Drilling Co., 2, Ltd. License � 5 Phone <br /> � e . <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /7 RECONDITION /_7 DESTRUCTION f7 VJ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> other /_7 <br /> i `DISTANCE TO NEAREST: `SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIEI;DCESSPOOL/SEEPAGE PIT OTHER C + <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE � TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial li Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domeetic1publid. ,-._- _ ..Driven -Gauge of -Casing <br /> Irrigation 11 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 L <br /> Type of Pump Vertical. H.P. IOU <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 owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTI A FINAL INSP,E 0 . <br /> ' SIGNEDTITLE President <br /> { W TLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DAT <br /> E H`1426 Rev. 1-174 E . .. fi - <br /> 1-74 2M ` <br />