Laserfiche WebLink
_ y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 7dtJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED <br /> Date Issued �6 <br />` Application is Hereby made tb the San {JoaquineLocalIn rtealth District fora permit <br /> and/or install the work herein described. This application is made in compliancetwith nSanuJoaquin <br /> County Ordinance No. 1862 and the Rules and 'Regulations af "the San Joaquin Local Health District. <br /> Aw <br /> ?`f7oe7. 1 <br /> .TOB ADDRESS/LOCATION 150' ?South�Shelto� Rd. & Mile East Escalon-Bello <br /> NSi1S TRACT �j <br /> Owner's Name Willism C. Anderson <br /> Phone <br /> Address 22078 E. Comstock Road4 Linden;, -Calif .95236 <br /> City <br /> Contractor's Name Purviance Drillers P.O.Box 64 •T�lnden License4 240107 phone s <br /> 24010-_ 991 ,4468 <br /> TYPE OF WORK (Check); NEW WELL . <br /> I7 DEEPEN /-7 ,I{ECO_ NDITION /7�DES.TRbCTION_/`f <br /> PUMP INSTALLATION T <br /> / %�..pI3MP REPAIR /� PUMP REPLACEMENT �� <br /> Other ?/ / '' - - <br /> DISTANCE TO NEAREST SEPTIC TANK 300i SEWER LINES '~ <br /> PiT. PRIVY. .; <br /> SEWAGE DISPOSAL FIELD _ <br /> SSPOOL/SEEPAGE`PIT <br /> CEOT...HER.; ` 4 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL . --PUBLIC 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL " <br /> Industrial x CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of,Well Excavation- <br /> Domestic <br /> /private__ _—_ <br /> �_ Domestic/public— - -- .- Drilled T G <br /> - - ia;r—6-f— <br /> 11 Caei�g �' 2m <br /> Driven auge of Casing_ <br /> O <br /> ][ Irrigations I Gravel Pack Depth of Grout Sealy <br />_..•- Cathodic Protection . _jam Rotary Type of Grout <br /> Disposal I Other Other Information,_ <br /> Geophysical <br /> Surface Seal :iI sCalled 'Bv. <br /> PUMP INSTALLATION: Contr "� <br /> actor ;,Purulence Dril-lerst <br /> Type of Pump <br /> _.__ S H.P. _.40 <br /> PUMP REPLACEMENT: / / tate Work Done <br />-` _ 4. <br /> PUMP -REPAIR: <br /> / / State Work Done <br /> t <br /> DESTRUCTION OF WELL: .Well Diameter F <br /> Describe Material and Procedure Approximate Depth <br /> _ ----- <br /> Ihereby 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'ta 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.-Vell. in.use.... The above � <br /> Lnformation is true to-the besr.of my. knowledge and belief. I WILL CALL FOR A GROUT IN <br />'RIOR TO G tWING ' INAL INSPECTION. <br />"IGNED <br /> TITLE Partner <br /> PLOT PLAN ON REVERSE SIDET. <br /> 1HASE I F R DEPARTMENT USE ONLY <br />►PPL TION ACCEPTED BY <br /> DDDITIONAL COMMENTS: <br /> PHASE <br />,NSPEGTION BY P E I FINAL INSPECTIO <br /> DATE N— - <br />' <br /> INSPECTION B DATE <br /> E H 1426 Rev. 1-•74 � _ <br />