Laserfiche WebLink
t ' SAN JOAQUIN 'DOCAL-HEALTH. DISTRICT <br /> FOR OFFICE USE: ' —L601 E. Hazelton Aw-'7. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> i <br /> JOB ADDRESS/LOCATION 30836 E.Combs Pd. Escalon Ca. 95321D CENSUS TRACT 12-2-R2F <br /> f Owner's Name Lawrence R. -Vest � ,,Phone =838-2824 <br /> i Address 08 6 East Combs Road City Escalon Ca. <br /> Contractor's Name Carrell & Canape Urillknp�+! License # 28(8 OPhone 532...3I81 <br /> Routp 6 Box 57- it fca- 95370 <br /> - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL `/ / DEEPEN /_/ RECONDITION / / _DESTRUCTI_0 / �_ <br /> PUMP INSTALLATION"/� -PUMP` REPAIR''/ / PUMP f REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 SEWER LINES PRIVY <br /> SEWAGE DISPOSAL FIELD _4>0 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia, of Well Excavation 73 inch <br /> Domestic/private Drilled Dia, of Well Casing nc <br /> Domestic/public Driven Gauge of Casing 9 �e (( __ <br /> YES- Irrigation_ .. �Graye] Pack Depth of .Grout-Seal `11 <br /> Cathodic Protection YM Rotary Type of Grout, 1101 <br /> D`isp6sal" Other- Other, Intol-nation - -� <br /> Geophysical _ Surface Seal -Installed B <br /> PUMP INSTALLATION: Contractor - Carrell & Canepa . <br /> r <br /> Type bf Pujnp,. Berkley -7.83H2 submersible H.P. 20 <br /> 9' PUMP REPLACEMENT: / / State Work Done <br /> PUMP-..REPAIR: / / State Work Done - <br /># -- <br /> AES-TRUCTION'.OF WELL: Well Diameter ``�, Approximate Depth <br /> s Describe Material4.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 Districtal <br /> WELL DRILLERS REPORT of the well and notify thein 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 FINAL IN ECT ON. <br /> SIGNED TITLE 01MR ' <br /> „(DRAW-:PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE-4 /17//Z;Z.' <br /> ADDITIONAL COMMENTS: <br /> b PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY AIA DATE INSPECTION BY DATE 7-7) <br /> 3/76 2M <br /> E H .1426 Rev. 1-74 <br />