Laserfiche WebLink
li. SAN ,JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: -.=:± x`1601 E. Hazelton Ave. , ,Stockton, Calif. )fa � E� <br /> Telephone: (209) 466-6781 <br /> I� a- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77lv1 <br /> THIS- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /v -31-7 <br /> V (Complete In Triplicate) ti <br /> f 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. <br /> .JOB ADDRESS/LOCATION <br /> RIVER RD.-MILE EAST OF CARROLI'ON RD.� � CENSUS TRACT <br /> SOUTH SIDE <br /> Owner's Name- ISABEL BETTENCOURT Phone 599-38-02 <br /> Address 20442 .E. -RISER RD. City ' RIPON <br /> Contractor's Name BENNINGS BROS. DRILLING,-,:CO. INC. License # 290813 Phone 545-=1 185 <br /> 3525 PELANI)ALE AVE. MUD <br /> TYPE-OF-WORK- ,(Check) :, NEW.WELL /)... -DEEPEN /-7/ RECONDITION-'/_/ DESTRUCTION ? <br /> I PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /7 <br /> Other j <br /> DISTANCE TO NEAREST: SEPTIC TANK bnl SEWER LINES , PIT, PRIVY p�`nl � <br /> •SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE (RO PIT <br /> PROPERTY LINE'- PRIVATE DOMESTIC WELL '` PUBLIC_­bOMESTIC WELL. <br /> INTENDED USE a. TYPE OF WELL,. a, _ CONSTRUCTION SPECIFICATIONS . <br /> Industrial �. `Cable 'Tool Dia, of Well. Excavation 12" Q <br /> X Domestic/private Drilled Dia, of Well Casing 81? plastic <br /> Domestic/public sDriven Gauge of Casing 160 wall___ <br /> Irrigation ',Gravel Pack Depth of Grout Seal T 501 ! <br /> Cathodic Protect_ n _X_ <br /> . <br /> ioX Rotary Type of Grout Bentonite t" <br /> Disposal I '=.�i-4=Other r-.Y-a - Other Information Slab--by owner <br /> Geophysical - -- Surface Seal Installed By: driller <br /> - <br /> PUMP INSTALLATION: Contractors <br /> Type .of `Pump H.P. <br /> PUMP REPLACEMENT: /�.%, ' State Work Done <br /> PUMP -REPAIR: / / State Work Done' f Od✓� <br /> ll �-iRUC�TION �OFWE�LL. Wel Diame'Weter �,� ,q,� �U �� '�"Ap xamate Depth <br /> Describe--Mate-r- a1 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 we11 ''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 /> I '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 HEN ING .BROS. BY TITLE <br /> (DRAW PLOT PI4N ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. DATE` �Jr <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE !II/FINAI, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE O <br /> . �2M � <br /> E H 1426�Rev. l-74'R �y � . It�2�i�7� - ,{�t,�• a lG <br /> s -�� <br />