Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE• rv" <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone_: _(2p9) 466-6781 <br /> APPLICATION FOR WELe CONSTRUCTION OR PUMP PERMIT Permit No. <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/LOCATION LONE TREE RD. ESCALON-BELOTA RD.. CENSUS TRACT <br /> Owner's Name JESSE WELCH Phone 838-9192 <br /> I <br /> Address J1i.964 ESCALON BELLOTA RD. pity ESGALON,CALIF. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 2 90 813 Phone - 522-,031 <br /> 0 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL XV DEEPEN/ / RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION/ / PUMP REPAIR "/—/ PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK '701 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL aA/ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.-.of--Well Excavation llrr <br /> m. XX Domestic/private Drilled Dia. of Well Casing 6 T rP Ta-s i c <br /> Domestic/public Driven Gauge .of..Casing' <br /> Irrigation Gravel Pack Depth of Grout Seal_�___5U T .t- <br /> ` Cathodic Protection Rotary Type of Grout Bentonite ^P <br /> Fr` Disposal Other Other Information 61a U b3Fer <br /> y` Geophysical Surface Seal Installed By: l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Des ribe Material and Procedure <br /> 22r <br /> Ier�i e�gree Tv'effiy-ly wi f a17 1'a as..and regu ations o of 'MS'ai—Jbaquiri—t6ca'1 -Hearth <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew we11, I will furnish the San Joaquin Local Health District <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 L FOR A GROUT INSPECT ON <br />'RIOR TO ROUTING AN A FIN INSPECTION. <br /> SIGNED � TITLE <br /> DRAW PI; T PLAN ON RE RASE SIDE) <br /> FOR DE TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION PHAS II , IN INSPECTION <br /> INSPECTION BYEDATE INSPECTION BYi�' DATE <br /> T <br /> E H 1426 Rev. 1-7.4 3/76 2m <br />