Laserfiche WebLink
z ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo-s-OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-LN-11�Tw <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued alto <br /> I. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Flealth 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 Rulesnd Regulations of the San -Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION J°.26 t. River Road CENSUS TRACT <br /> Owner's Name Phil Adrian Phone $38-2337 <br /> Address J2655 E. River Road City ' Escalon <br /> Contractor's Name Howk We11 & E ua . Co. Inc. <br /> _ License # 2l� Phone 5.24-927 5 <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -/7 RECONDITION /_T DESTRUCTION,f f <br /> PUMP INSTALLATION/x/ PUMP REPAIR'/-7-pump REPLACEMENT /? <br /> Other /_7 . <br /> DISTANCE TO NEAREST: SEPTIC TANK r. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation 2 tf <br /> Domestic/private Drilled Dia. of Well Casing j611 <br /> domestic/public Driven Gauge of Casing _ . 219 <br /> X Irrigation Gravel Pack Depth of Grout. Seal bentonite „�`! <br /> Cathodic;Protection X. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By <br /> ? INSTALLATION. Contractor Howk Well & Equip. Co inc <br /> Type of Pump deep-well turbine 4 H.P. 100 <br /> SUMP REPLACEMENT: . / / State Work Done - E � <br /> E <br /> PUMP,'.•REP — ' <br />� xR: - - - -- -�/ -J �State�=Work Done- <br />'r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 k 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 anew 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 ANDA fINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> DE TNVNT USE ONLY <br /> PHASE I t <br /> APPLICATION' ACCEPT rX <br /> DATE �2_ - ZQ Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE� TII ,FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY ,,. I: DATE Xla <br /> E H 1426 Rev. 1-74 1.J�k 7nr <br />