Laserfiche WebLink
NSAN JOAQUI LOCAL HEALTH DISTRICT <br /> i <br /> FOFs,rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7,6. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �. (Complete In Triplicate) <br /> Application is hereby 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 T-SIES;TATCOURT--OFF MCARTHUR BLVD-. TRACY CENSUS TRACT -Zk-14,0-06 <br /> k' 1 <br /> Owner's Name TERRA WEST. CONSTRUCTION Phone 835- F738 <br /> Address P. 0. BOXa 1216 City . TRACY, CALIF. ' <br /> Contractor's Name Hennings Bros. Drilling Co., Inc. a # 290$1 522--1031 <br /> • 3Fhone <br /> 'sem .' -�t'4.�. _ �.4�__--•• :moi:. .,.,3:_°Y- '_ ..-.-�r�4+.,:: _5.l�F _ �,�ab.wfr�---a 5�.,_.,.-_._.�� _.R.._' Wit,.. :may,! <br /> TYPE OF T4 RK (Check) NEW WELL /� DEEPEN /_� RECONDITION /� DESTRUCTION /�" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /% 4) i <br /> STANCE TO NEAREST: SEPTIC TANK <br /> /00 SEWER LINES / p'� PiT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC T C <br /> INTENDED USE WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11'r <br /> X Dome stic/private Drilled Dia. of Well Casing c: <br /> Dome a tic/public Driven _ Gau e_ <br /> --ii-1 at Long. ��„"_. �. '-x. g.... of-Casing-- .r _ f <br /> g Gravel Pack Depth of Grout Seal t 0 <br /> Cathodic Protection X Rotary Type of Grout Ben ton e <br /> Disposal - Other Other Information Slab by <br /> owner <br /> —GeophysicalSurface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / , State. Work Done <br /> �— r <br /> Sta'te�Work"Do�e'm"'"- <br /> ES TRUCTION OF WELL: Well Diameter <br /> Describe Material. and Procedure Approximate Depth <br /> I <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 �j <br /> after completion of my work on a new,well, I will furnish the San Joaquin Local Health District a <br /> WELL DRI <br /> LLE ORT of the well and notify them before putting. the. well in.use.. The above <br /> informat s rue best-of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ING INAL INSPECTION. <br /> GNE L L <br /> (DRAW PLOT PT ON REVERSE SIDE <br /> FO D PARTMENT USE ONLY <br /> PHASE I t - - P <br /> APPLICATION ACCEPT BY DATE <br /> ADDITIONAL CO S-: , <br /> SE II GROUT INSPECTION P E IIINSPECTION INAL INSPECTION <br /> INSPECTION Y . DATEINSPECTION BY DATE { <br /> H 1426 Rev. . <br />