Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT Y 7 <br /> LFOR 'FICE� USr---E; 1601 E. Hazelton Ave. , Stockton, Calif.� C�'J Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES l 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 /> JOB ADDRESS/L'OCATION 10663 -N. Hi hway 8$ CENSUS TRACT <br /> it owner's Name Jesse and Aileen Souza Phone 931-0397 <br /> Address - x_10663 `N Highway-88 city <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License #290813 Phone545-17$5 <br /> . i <br />`= <br /> TYPE-OF WORK--(Check): NEW. WELL &/ DEEPEN RECONDITION / / DESTRUCTION_/_ ` <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO 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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q ,� <br /> Industrial Cable Tool Dia. of Well Excavation 26" _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public, Driven . Gauge. ofr-Cas ng�_ _ „gauge <br /> _ x Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout none <br /> Disposal Other Other Information ;_ <br /> Geophysical Surface Seal Installed B : nonev� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H,P: <br /> _ r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: Stat6 Work Done <br /> D.ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the ;an 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSPECTTON. <br /> SIGNED TITL]Driller <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ 4 <br /> OR D PARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE >? 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION, BY ` DATE INSPECTION BY / DATE P I- -� <br /> E H 1426 Rev. 1-74 +x!77 2M <br />