Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0P� OFFICE S:E-"�-' 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone :- (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �$8 <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health- District. <br /> JOB ADDRESS/LOCATION 81.80 E BRADY AVE,.- -MILE EAST OF S. MANTECA CENSUS TRACT - <br /> RD. $ SOUTH SIDE <br /> Owner's Name BORGES DAIRY JOE '& FRANK BORGES Phone _ 823-6625 <br /> Address 8180 E'. BRADY AVE. City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC . License # 290813 Phone 545-118 <br /> -3525-PELANDALE AVE. <br /> TYPE OF WORK (Check) : NEW WELL )V DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION PUMP REPAIR, / / PUMP REPLACEMENT <br /> Other ` <br /> 3n <br /> DISTANCE TO NEAREST: SEPTIC TANK 20/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /- � CESSPOOL/SEEPAGE PIT OTHER Wet,4-.�,5' <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 18ci <br /> Domestic/private Drilled Dia, of Well. Casing 1011 <br /> Domestic/public Driven Gauge of Casing x/16 GA Cz <br /> Irrigation X Gravel Pack Depth of Grout Seal 01 <br /> Cathodic Protection , Rotary Type of Grout CEMENT <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <br /> _X_ DA IRY. -- - - - <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. <br /> PUMP 'REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <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 . 5 INC . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT.USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - ---G,' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION PHAS II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYA,D TE <br /> E H 1426 Rev. - I-74 <br /> ��0177 _ <br />