Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT CS <br /> E' tOFFICE USE: 1602 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /";z <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 an Vh Rules and Regulations of the San Joaquin Local Health District. <br /> 'JOB ADDRESS/LOCATION 1� mile south of Co peropolis /10 W of CENSUS TRACT <br /> sca on a o a . <br /> Owner's Name R. & i:J. Sanguinetti phone <br /> Address City Linden <br /> 68 <br /> Contractor's NamePuryllanceers License # 240107 Phone 9 1- <br /> 4 <br /> TYPE OF WORK (Check): 1, NEW WELL g7 DEEPEN 1-7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /R/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> .11 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 <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> --Domestic/pr-ivati — Drilled Dia, of Well Casing <br /> Domestic/publicDriven Gauge of Casing 3/1 Plate <br /> i Irrigation II Gravel Pack Depth of Grout Seal _•.•..,•.• _ <br /> -- Cathodic Protection Rotary Type of Grout <br /> Disposal T Other Other Information <br /> Geo h sical . <br /> P y 'Surface Seal. Installed B . <br /> k it <br /> PUMP INSTALLATION: Contractor Purviance drillers <br /> :l Type of Pump turban H.P. 75 <br /> PUMP REPLACEMENT: u / / State Work Done <br /> ' PUMP '.REPAIR: J-7 State Work Done <br /> A$1—RUCTION OF WELL: Well Diameter , Approximate Depth <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 FIFTEEN DAYS <br /> I after completion of my; work on a new well, 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 td: the best of my-knowledge and belief. I WILL CALL FOR "A -GROUT INSPECTION <br /> PRIOR TO GROUT GAND A FINAL INSPECTION. <br /> SIGNED TITLE P rine <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` - � <br /> .._. .. DATE <br /> ADDITIONAL C0b=NTS: --- - . . _..,..•._,. .. ._ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> k INSPECTION BY i3 DATE INSPECTION BY DATE <br /> t E H 1426 Rev. 1-74 1-74 2m <br />