Laserfiche WebLink
SAN JOAQUIN LOCAL" HEALTH DISTRICT " <br /> rOF OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'Iy�l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� Jr <br /> (Complete In Triplicate) <br /> Application is Aereby 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. a <br /> JOB ADDRESS/LOCATION VEB I G, N BD.=1Mj.EAST OF HWY 99 FRONTAGE- CENSUS TRACT ' <br /> NORTH SIDE <br /> Owner's Name DON PETERSEN Phone <br /> Address 581+1 VERIGAN RD. City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone _545-11_85 <br /> 2 PELANDALE AVE. MOD. 95350 <br /> TYPE OF WORK (Check) : NEW WELL )[—/ DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK _300SEWER LINES--- . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL "" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q�1 ' <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> Domestic <br /> -- - -�— <br /> /private Drilled Dia, of Well Casing 1 2tt — ' <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection501 <br /> X Rotary Type of Grout ;7n _,,y,� <br /> Disposal Other ' Other Information Sla-b-by Omer <br /> Geophysical Surface Seal Installed By, dri]„3 er <br /> PUMP INSTALLATION: Contractor A <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done f <br /> PUMP -,REPAIR: / / State Work Done <br /> DES•TRtTCTION OF WELL: Well Diameter Approximate*Depth <br /> .r 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 i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <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 HENNINGS BROS. DRILLING CO. INC. b TITLE <br /> Ljf- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY 10DATE ! j <br /> ADDITIONAL COMMENTS: <br /> 4 <br /> PHASE II GROUT TRSPECTION PHAS I I/FI AL INSPECTION <br /> INSPECTION BY _ TE INSPECTION BY DATE <br /> 5�) .iy* <br /> E H 1426 Rev. =) on i/v more <br />