Laserfiche WebLink
T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: ` 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-8�lrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _, 7.� <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 /> JOB ADDRESS/LOCATIONx <br /> urbara e r Rd CENSUS TRACT <br /> Owner's Name Joe De Costa Phone 835-1522 <br /> Address 11_50 S. Bird Rd. City Trady - <br /> Contractor's Name Hennin s Bros. D ' lling Co. Inc. License # 290813 Phone 522-1031 <br /> 2200 W. Rumble Rd. , Modes o <br /> TYPE OF WORK (Check): NEW WELL /X7 DEEPEN17 7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5S SEWER LINES 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 <br /> X Domestic/private Drilled Dia, of Well Casing _ 11 O <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5,p: <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY:.�, driller <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: %// State Work Done r� <br /> PUMP REPAIR: _ /7 'State Work Done _ <br /> ES•TRUCTION OF WELL: . Well Diameter Approximate Depth S <br /> Describe Material and Procedure S <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 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 of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION �J <br /> PRIOR TO GROUTING ADID A FINAL INSPECTION. <br /> SIGNED 41- .44 TITLE , <br /> (DRAW.PLOT PLAN ON REVERSE SIDE <br /> R DBPWMENT USE ONLY IFN <br /> PHASE I a- <br /> APPLICATION ACCEPTlr" DATE / <br /> ADDITIONAL COMME <br /> F ..I UT INSPECTION - � P I /B AL INSPECTION <br /> INSPECTIBY DATE - 'S �5 INSPECTION BY ', i.. - DATE � •„ � <br /> yt :;E H 142-6 Rev. 1-74 1--74 2M <br />