Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:- (209) 466-6781 <br /> M APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. ��_/� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made. to the San <br /> (Complete <br /> Joaquin eLocalriplicateHealth' 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 /> 6.1oJOB ADDRESS/LOCATION 6BBFJ MD1 RD 2_-q]-00410-0Z <br /> CENSUS TRACT <br /> Owner's Name PHILLIP CHINCHILO & SONS- <br /> Phone 982.0 44 <br /> Address 208+8 E. RIVER RD. <br /> City RIPON_CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License #116322 Phone522_5643 I <br /> TYPE^OF WORK (Check): NEW WELL/ DEEPEN / / WRECONDITION /_7 DESTRUCTION /_7N" <br /> 14 PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> 5 <br /> Other /% --- , <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C7 <br /> INTENDED USE to <br /> TYPE OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation cr <br /> Domestic/private Drilled Dia. of Well Casing rr s <br /> _ Domestic/public Driven Gauge of Casing rr ° <br /> X Irrigation Gravel Pack Depth of Grout Seal N• <br /> Other X Rotary . <br /> Type of Grout- <br /> Other Other Information <br /> - a <br /> PUMP INSTALLATION. Contractor E <br /> Type of Pump <br /> Y. . H.P. <br /> PUMP REPLACEMENT:, F / / State-Work Done . <br /> -1r-7 z._ �2-1 -7 <br /> PUMP REPAIR: / / " State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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. <br /> SIGNED <br /> y TITLE <br /> RAW LOT PLAN ON REVERSE SIDE { <br /> P <br /> PHASE I -- FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II -GROUT INSPECTION I / AL INSPECTIO <br /> INSPECTION BY -_ DATE INSPECTION BY/ <br /> DATE <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING AND FINAL 'INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />