Laserfiche WebLink
_• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . <br /> r'OS OFFICE USE: 1601 E. Hazelton Ave. , Stockton,Calif. <br /> Telephone: (209) 466-6781. <br />' <br /> LPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-.41 $8 <br /> Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ( -3-7r <br /> :I (Complete In Triplicate) <br /> Application is hereby de 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 /> .27a <br /> JOB ADDRESS/LOCATION Corral Hollow &.Valpico Rds . CENSUS TRACT . J ` ' ` <br /> Owner's Name GZ,411i,,on �'. Phone 835-W" <br /> if <br /> Address 23034 S. Hansen Rd. . City Tracg, Cal. <br /> Contractor's Name Hennings Bros . Drilling Co, , Inc License 90$13. phone 522-1031. <br /> k um e o es o , a . • 95350 <br /> TYPE OF WORK (Check) . NEW WELL 'XV DEEPEN -/7 RECONDITION /7 DESTRUCTION f ]" <br /> iUMP INSTALLATION / f PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other / / . . . . . . <br /> F DISTANCETO 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 i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1177 6-5/8 U <br /> XX Domestic/private XX Drilled Dia. of Weil Casing = ?? O <br /> Domestic/public Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout .Seal 501 <br /> Cathodic Protection XX Rotary Type of Grout Bentonite <br /> Disposal. Other Other Information Slab by owner <br /> Geophysical �} Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor F _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , I�— <br /> / / State Work Done <br /> PUMP '.REPAIR: l�— <br />... -- __.�.:�.:�..:.._ -./ _/. �S to to�Work Done <br /> DESTRUCTION OF WELL: well Diameter Approximate Depth CA <br /> Describe Material and Procedure �. <br /> A, <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 of1the 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'OINAL INSPECTION. - <br /> SIGNED - E .w PRjLLING . , INC . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP <br /> PHASE I UMENT USE- ONLY <br /> � � gg <br /> APPLICATION ACCEPTED DATE __:9 �- <br /> ADDITIONAL COMMENTS: I� <br /> PRASE II GROUT INSPECTION PHASE III FINAL, INSPECTION <br /> INSPECTION BY A DATE INSPECTION BY DATE Z 7� <br /> E H 1426 Rev. 1-74. h/75 2M <br />