Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stocktbn, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL�CONSTRUCTION OR PUMP PERMIT Permit No.,7 <br /> w r rti. <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 workilherein described. This application is made in compliance with San Joaquin <br /> County Ordinance. No. 1862_ and. the Rules and Regulations of the San Joa g u n Local Health District. <br /> 2�rgo nj 3_Z`F6 �a � <br /> JOB ADDRESS/LOCATION 1.1�Hl7e East Esaaloln-Be?lota Fd. & 1 We South F,0O&M TRACT <br /> Owner's Name Ter171JObuson °„;a +- Phone <br /> Address P. OJ[Box 705, Linden, Calif. 95.236- City <br /> Contractor's Name Roes urviance & Son, .P.U.BGx 1S5JAn�den, License # 130532 Phone 837-3480 <br /> T q� a� 952 c3 i <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION .A l PUMP REPAIR / / PUMP REPLACEMENT f� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5 SEWER .LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 2501 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ...2%' PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i x Cable Tool Dia. of Well Excavation H <br /> x Domestic/privateli Drilled Dia. of Well Casing Sn 1 <br /> Domestic/public Driven Gauge of Casing 10 <br /> Irrigation Gravel Packer Depth of Grout Sear 50' <br /> Cathodic Protection Rotary Type -of=•Grout _Meet Cement <br /> Disposal Other Other Information 1211 jacket <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ross Purviance & Son <br /> YPe of Pump Submersible H.P. 10 <br /> PUMP REPLACEMENT: �/ / State Work Done <br /> PUMP .REPAIR: �/ / State Work Done <br /> DES-TRUCTION OF WELL: - Approximate Well Diameter pp Depth <br /> Describe Material and Procedure 1 <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 or4regulating well "constructI 6_n. Within FIFTEEN DAYS <br /> after completion of myil 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 /> inf ormatigm, is r e to11the best of my. knowledge and belief. I WILL CALL.. FOR A GROUT INSPECTION <br /> PRIOR TO TI G AND A FIN AL `INSPECTION: ! <br /> SIGNEDTITLE Owner <br /> tDRAW PI T PLAN ON REVERSE SIDE ' ; <br /> { 'X-XOR,DEPAR NT USE ONLY <br /> PHASE I <br /> APPLICATION"ACCEPTED':BY x s f - DATE Id <br /> ADDITIONAL COMMENTS: 'I <br /> PHASE II GROUT INSPECTION I PHASE III/FINAL INSPECTION <br /> INSPECTION BY & DAVE INSPECTION BY DATE <br /> 3/76 2 <br /> E H 1426 Rev. 1-74,4 <br />