Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE VSE: 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> t _ <br /> Telephoner (209) 466=67$1 <br /> C APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> f T1f1S, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S �/ <br /> (Complete In Triplicate) ��O <br /> Application is hereby made to the San Joaquin Local Health District,'for ,a permit to construct <br /> and/or, install the work here1n described. !I[This application is made in compliance with' San, Joaquin <br />! County Ordinance Na. 1862 and the ,.Rules•.and Regulations of the San Joaquin Local. Health.-District. <br /> ! <br /> JOB ADDRESS/LOCATION HOR T-0 --.?MILE I I " :WORTH OF WALNUT GROVE <br /> C NSUS TRACT.- <br /> VE Rl. <br /> Owner's Name COUNTY OV AN JOA UIN I; WEST SIDE <br /> Phone <br /> Address-__ .LR <br /> _7�7-.FCity -S- <br /> Contractor's Name HENNINGS `BROS. DRILLING CO. INC._ License �6 290813 Phone 545-1185 <br /> 3525 P DA AVE., :MODE S T 0 CA . 953 50 <br /> t <br /> 4TYPE OF WORK (Check) : NEW WELL / % DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / ;/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1/ / !i <br /> DISTANCE TO NEAREST: SEPTIC'..TANK SEWER LINES PIT PRIVY S <br /> SEWAGE �DISPOSAL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �p CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation -4,1 ! <br /> Domestic/private --- <br /> p Drilled �j Dia, of Well Casing 1 tr <br /> Irrigation <br /> Domestic/public Driven El Gauge of Casing GA <br /> Irrigation IR Gravel Pack Depth Grout Seal — <br /> Cathodic Protection Rotar5Q, CEMEN <br /> y T of Grout Ott CONDUCTOR PIPE <br /> Disposal X Other REVERSE t Information SLAB-BY OWNER <br /> Geophysical <br /> MUNICIPAL ROTAR Surfac Seal Installed By - DRILLER <br /> � <br /> PUMP INSTALLATION: Contradtor <br /> Type of Pump I� H.P. <br /> 1.1 <br /> PUMP REPLACEMENT: / / State Work one <br /> PUMP .REPAIR: <br /> / / State Work one <br /> DESJRUCTION OF WELL Well Diameter I; Approximate Depth <br /> Describe Material a Procedure <br /> I hereby agree to comply withfall laws and regulations a the San, Joaquin Local Health Distric ' ° <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS • <br /> after completion of my work on anew well, 1 will furnish the San Joaquin Local Health DistricC'a <br /> WELL DRILLERS REPORT of the well and notify1[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 AND A FINAL INSPECTION. I <br /> SIGNED HENNINGS BROS,. DRILLING CO. INC. BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE'SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY ! DATE 7 P <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ! INSPECTION BY DATE <br /> E H 1426 - Rev. . 1-74 6177 2M <br />