Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> C Telephone: (209) 466-6781 <br /> C APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lsf <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> Applications is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or instill the work herein described. This application is made in compliance with San Joaquin; <br /> County Ordnance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District., <br /> JOB ADDRESS/LOCATIONLL.�.� CENSUS TRACT <br /> Owner's Name Carl Hedstrom Pho 9$2-09$1 <br /> ne <br /> Address 9�+9 E. French Camp Rd, <br /> City .x 1_/Z �',_. 9 '-X 3 <br /> Contractor's Name Hennings Bros . Drilling Co. ,' Inc.. ' e 2,90$13 Phone .522-1031 <br /> 0 West Rumble o es , � <br /> TYPE OF WORK (Check) : NEW WELL ,XT DEEPEN '/-7 . RECONDITION F7 DESTRUCTION /7 <br /> EPUMP INSTALLATION/ / PUMP REPAIR -/-7-pump REPLACEMENT %7 <br /> rOther <br /> DISTANCE TOI�NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i1 PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. . of Well Excavation <br />�.. Domestric/private Drilled Dia. of Will Casing <br /> Domes !ic/public Driven Gauge of Casing <br />—77-- IrrigattionGravel Pack Depth of Grout Seal �g <br /> Cathodic Protection Rotary Type of Grout ' �+ <br /> Disposal Other Other Information 4 <br /> Geophysical <br /> Sur face Seal Installed By, <br /> PUMP INSTALLATION: Contractor <br /> Type of- Pump H.P. <br /> PUMP REPLACEState Work Done <br /> PUMP '.REPAIR: / / Slate Work Done . <br />)ES•TRUCTION QF WELL: Well Diameter Approximate Depth <br /> .I 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 '-cbnstruction. 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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 1IJbRAW PLOT PLAN ON REVERSE SIDE <br /> :i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION j11 <br /> CNSPECTION BY DATE INSPECTION BY DATE `Tr" ] <br /> I <br /> E 11 1426 Rev. 1-74 _ - �._ P-.,te/794 9M <br />