Laserfiche WebLink
� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76�/K_3.�) j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued 3 Q2lf-7( <br /> s (Complete In Triplicate).- <br /> .Application <br /> riplicate) -.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 Nd. . 1862 and the .Rules and Regulations of the San loagnin Local Health District. <br /> *6 w <br /> JOB ADDRESS/LOCATION MI WEST OF MC HKNRY .AVE. CENSUS TRACT 3 <br /> SOUTH S:.D <br /> Owner's Name BINE ANDERSON ' Phone 838 -*5 <br /> Address 4 E,..- lou h Rd. City ` ` " ESCABDN- <br /> Cantractor'.s Name BE NNING S BROS. DRILLING CO. INC'. ' License # '2908.1 3 .Phone 522-1031 <br /> 00 W. RUMBLE RD. MOD <br /> TYPE OF WORK (Check): NEW WELL g DEEPEN ,/_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP .INSTALLATION Cl PUMP REPAIR '/-7 PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK LAj 'II- SEWER LINES f5,�,-F 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 rr <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ;;,,..�yGauge-of Casing Y <br /> Irrigation Gravel Pack Depth of Grout Seal, rL _.,..- <br /> Cathodic Protection '_` Rotary Type of Grout <br /> Disposal Other Other Information. ,91 ,h�n�.m�;,t_ <br /> Geophysical Surface Seal Iristalled B <br /> PUMP INSTALLATION; Contractor <br /> t Type 4.of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: 17 'State Work Done <br /> DES.TTRUCTION,OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> I hereby agree to comply with all laws aced 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 newwell, I will furnish the 'San Joaquin Local Health District a <br /> WELL DRILLERS R.EPORT.: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 GROUTING -AND A' PINAL INSPECTION. F. <br /> SIGNED - BY TITLE SEG <br /> r DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE 'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6PI1DATE <br /> ADDITIONAL- COMMENTS: � <br /> P4WT11 MUTANSPECTigm - PHASE III FINAL INSPECTION- <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H1.426 <br /> Rev. 1-74 475 2m <br />