Laserfiche WebLink
�Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi:OFFICE USE: 1601 E."Hazelton. Ave. , Stockton, Calif. <br /> _y Telephone: (209) 466 -678L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ili-AS <br /> THIS PERMIT EXPIRES 1 .YEAR PROM .DATE ISSUED.., Date Issued 3-.�4-74 <br /> (Complete. lu. Tr,iplicate) <br /> Application is hereby made to the San Joaquin Local Health District for- a permit -to construct <br /> and/or install the wank herein described. <br /> This application is made ,in, compliance with San Joaquin! <br /> County Ordinance No 1862 and the Rules and Regulati'ons. of the. San Joaquin Local .Health District. <br /> JOE ADDRESS/LOCATION 2296h F _ .RAIG pD:gJZT BAST OF SFXTON 1-11) ,.. .CENSUS TRACT <br /> SOUTH SIDE. <br /> Owner's Name -JOHN <br /> . _ Phone 8-18-2620 <br /> �. <br /> City `ESCALON' ' <br /> Address._ R', CRATG ,RDi <br /> Contractor's Name ,&,wig l s MOS DRILUNG CO..INC• .` License # 081 Phone 22-10 1 <br /> E MOD <br />` TYPE OF WORK (Check): NEW WELL -)X T DEEPEN '/7 RECONDITION l7 DESTRIICTION 1 <br /> PUMP INSTALLATION /� PUMP REPAIR/� PUMP REPLACEMENT /=T a <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES /Qp! '. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER P.6-35 R <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 �c V1 <br /> X Domestic/private Drilled Dia. -of Well Casing rT <br /> Domestic/public _ Driven Gauge of Casing _ 17 GA <br /> Irrigation. Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> l Disposal Other Other Information <br /> 6 y <br /> Geophysical , lay ownel: <br /> Surface Seal Installed Be <br /> x � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H'P' <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> PUMP ,REPAIR: State Work Done <br /> f -- Approximate De th _DESTRUCTION OF WELL: Well Diameterp <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 FIF'T'EEN 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 of. my knowledge and belief. I WILL CALL FOR A.'GROUT INSPECTION <br /> , PRIOR TO GROUTING AND A FINAL INSPECTION. SECe <br /> SIGNED WNNTNGS Dg0S, DlilLLING CO. INC., BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECT12f PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H-1&2!1 R". 1-74 <br />