Laserfiche WebLink
SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> FOS;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2G-a 474J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,1-,3e,-7,6 <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 Ru sand Re u1 tions of the San -Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATIONrTAIM .. i NogTH QV AT.LE11CENSUS TRACT <br /> Owner's Name EAST SIDE <br /> Phone —_ X99-3877 <br /> Address 1 8City E' <br /> CALON <br /> Contractor's NameDRILLINI CQ 0.4 Ilic License _29081 Phone _522-1031 <br /> TYPE OF WORK (Check)t NEW WELL ',97 DEEPEN 1_7 RECONDITION Lf DESTRUCTION / j <br /> PUMP INSTALLATION Cl- PUMP REPAIR I-7 PUMP REPLACEMENT-j9 <br /> Other L7 . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK _lop SEWER LINES hD' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Cu INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrlal Cable Tool Dia. of Well Excavationrr <br /> X Domestic/private Drilled Dia. of Well Casing 6-5/81, <br /> Domestic/public <br /> Domestic/public Driven Gauge of Casing <br /> 12 CIA <br /> Irrigation Gravel Pack Depth of Grout Sear. 1 <br /> Cathodic Protection X Rotary "��-"" <br /> Type of Grout BF,NjQ-gTTE _,.., <br /> Disposal Other Other Information <br /> Geophysical -SLAB-BX_OWNEE <br /> Surface Seal Installed 'B <br /> y.- DZILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP (REPAIR; L7 State Work Done <br /> S-TRUCTION OF WELL: Well Diameter / <br /> A proximate Depth <br /> 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 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 /> information is true to the•best of my..knowledge and belief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIflR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DR . INC, BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAA1- COMMENTS; <br /> PHAS I INSPECT( P I INAL INSPECTION" <br /> INSPECTION BY DATE INSPECTION j DATE <br /> tir E H 1426 Rev.. 1-74 r _ h/75 2M i <br />