Laserfiche WebLink
C `ti <br /> p � SAN JOAQUIN FOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 2:6LJ0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> e <br /> JOB ADDRESS/LOCATION South side Baker Road, iile East Jack Tone Road CENSUS TRACT <br /> Owner's Name Ferrari Bros. ~` Phone <br /> Address 5960 N. -A+rcherda'►e Road, Linden; Calif. 95236 City <br /> Contractor's Name Purviance Drillers Box 64 j inden ita7 if.95236License U240-107 Phone 937.-4j+68 t <br /> TYPE OF WORK (Check)* NEW WELL/ DEEPEN / RECONDITiON `' DESTRUCTION_ /_7 <br /> SUMP INSTALLATION/ �- PUMA'--REFAI-R-/W-:::PUMP-REPL'ACEMENT�/ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK, 4 . :r-SEWER .LINES ,` �.'`kPIT PRIVY -- - _ - ' 7 <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D014ESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a �' <br /> Industrial Cable Tool Dia. of Well Excavation - N <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> X Irrigation Gravel. Pack Depth of Grout Seal ` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed `By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /x/ State Work Done Repair and replace origins! pump <br /> PUMP`REPAIR: / / State Work Done <br /> s <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 /> informat true st•of my. knowledge and bei'.-ef. I WILL CALL FOR A GROUT�INSPECTION <br /> PRIOR GROU N INSPECTION. 7 <br /> SIGNE TITLE Partner <br /> DRAW°PLOT PLAN ON REVERSE SIDE <br /> DEPART NT USE ONLY <br /> PHASE I ---- <br /> APPLICATION,,ACEDB DATE <br /> ADDITIONAL COMMENTSi <br /> PHASE II GROUT INSPECTION PHASE XI,1 F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYVINW <br /> 7'0 <br /> � r <br /> E H 1426 Rpv_ 7_7' r L/7 _ 2M__ <br />