Laserfiche WebLink
SAN JOAQUIN LOCAL TIEALTH, DISTRICT <br /> FOR OFFICE USE:,¢ 1601 E. Hazeltori-Av'e.';fSt;oektoz7, Calif. <br /> Telephohe:,�., (209) 4b6-6781 <br /> APPLICATION FOR WELL GONS'TRtTCTION':OR PUMP PERMIT Permit No. 7 <br /> w THIS PERMIT 1EXPIRES ,11YEAR'{FROM,DATEjISSUED+� <br /> -- Date Issued / <br /> :tom r (Complete xIn Triplicate) f� �`�°t�x't'`d .psi I }„ ni. . <br /> App\\licatzon s ereliy .madei.tco :the",SaririJoaqu n= LocaI Iie.alth Districtf for. a..permit?to -construct ,t <br /> .and/or install the work herein described. This .,applicati�on�F sb°made-.iri.compliance--with: San'Joaquin <br /> County 3Ordinance)No err 186 Z andw the. Rules`)ands�Regulationsnof,�the,San-Joaquin.Local :Health District. <br /> !Za nCi s:.:.f.> <br /> -JOB ADDRESS/LOCATION r CENSUSF-,TRACT <br /> f h. <br /> 4• <br /> f hone , <br /> Owner's�Name r r. d,..�4 :� #p' ti, av <br /> Address `�/�:� � Gco �.. _ �. Ci <br /> ty _ ...�..�. <br /> Contractor's Name Henning Bros. <br />;� Rennin � Drilling Coe_,, Inc. License #116322 phone 522--5643 <br /> TYPE OF WORK (Cheuk), ` NEW WELL / DEEPEN / / RECONDITION /_/ DESTIRUCTION /7 <br /> - PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> . If <br /> DISTANCE TO NEAREST: SEPTIC TANK 4T_ SEWER LINES PIT PRIVYI1 <br /> SEWAGE DISPOSAL:FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> € INTENDED USE TYPE-OF WELL ,,, -N CONSTRUCTION SPECIFICATIONS ' <br /> ,Industrial -Cable Tool-' Dia. of Well Excavation___ <br /> Domestic/privateDrilled of-Well -Casing <br /> Domestic/public I DrivenF Gauge of Casing f ,� ., •°' �:•tJ s <br /> Irrigation ravel;Park, Depth, of Grout Seale d pj <br /> Other - <br /> Rotary , Type of Grout�� <br /> Other ' `-,, Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of"Pump H.P. <br /> PUMP REPLACEMENT: / f State Work Done �� } <br /> PUMP REPAIR: / / State Work`Do-n&- <br /> ,DESTRUCTION <br /> one,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I <br /> Describe Material and Procedure II <br /> 1( i <br />• I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 /> 'WELh 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� s <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) II I <br /> :FOR DEPARTMENT USE ONLY a s <br /> PHASE I s <br /> APPLICATION ACCEPTED BY <br /> DATE 7 <br /> ADDITIONAL COMMENTS ; s <br /> INSPEGT.ION BY / NAL INSPECTION <br /> INSPECTION BYP L)j E I . GRO T' DATE 7INSPECTI0� Z P S I DATE 7. /3-73 <br /> CALL FOR A GROUT INSPECTION <br /> PRIOR AND FINAL _INSPECTION. <br /> _._. .. _ II <br /> _- ___ _ ._ <br /> E H 1426 � _ _ <br /> (� 7 - 4Z_ Cd 4/72 lrt <br />