Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <F <br /> (Complete In Triplicate) <br /> Application ii-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 /> , f{'L it1- Fv POE 'tom'", : f�N 0-71- 330-- 07 <br /> JOB ADDRESS/LOCATION— I i1e North Comstock a Fine junction dead ends CENSUS+TRACT <br /> Owner's Name Chestnut hi?Z. Farms Phone <br /> Address P. ,0. Eox 132, Linden, 'Cc,1 if. 95236 City <br /> Contractor's Name.Purvi-a.nce' Dri1_j ers,r.G.Box 64.,�'.,inden,Ca7 if. License # ?1,.0 :07 Phone <br /> t f 9523 i <br /> TYPE bF WORK (Check}. EW`WFI,I, '/ IDEEPEN '/'`/ REC-6NDITIOI4 /7..,.DESTRUCTION+`/ <br /> PUMP INSTALLATION / / PUMP REPAIR /x/ PUMP REPLACEMENT /x-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 <br /> Industrial Cable Tool Dia. of Well Excavation T7 <br /> Domestic/private,- . "Drilled Dia. of Well Casing <br /> Domestic/public - Driven.-- __T_-� G'auge 'of-4. <br /> =Casing <br /> Depth of Grout Seal <br /> - <br /> x Irrigation Gravel Pack <br /> i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> F <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. _s <br /> PUMP REPLACEMENT: F-7State Work Done Full 30 HP Turbine, Re-Bowl and reps-ace pump <br /> .P.UMP_REPAIR:_;...e.,,.,.,;._._j ti State_Wo.rk-DoneL._ sou e _ <br /> DESTRUCTION 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 /> 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 GROUTING AND—A.— FINAL INSPECTION. <br /> SIGNED c TITLE Partner <br /> 4 4e-9 DRAW P T' PLAN ON RE ERSE SIDE „ !` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE -rill. <br /> APPLICATION ACCEPTED BY -- <br /> ADDITIONAL COMMENTS: <br /> .PHASE__II.GROVT ,,INSPECTTON _ PHAS /F AL INSPECTIO <br /> --- - DATE _: ,- - INSPECTION BY - . -ATE lQ <br /> [ INSPECTION �BY- � -�'�""";- <br /> 3/76 2M <br /> E H 1426 Rev. -1-74 -- <br />