Laserfiche WebLink
06, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: ?'.,'. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5-�9�lV <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-.2,a-7S' <br /> (Complete' In Triplicate) 212-t7w-t 7 <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct 'z <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/LOCATI racy-�1vd�& Larch Rd. Trac TRACTth of <br /> Owner's Name MARTIN RODRIGUEZ Phone 835-7$25 <br /> Address 21199 20. TRACY BLVD. TRACY , CAL. <br /> City i <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc : Li se #290813 Phone 522-1031 <br /> 2 um e o es o, 091-,-7953)U ,��,. <br /> - - - <br /> TYPE OF WORK (Check): NEW WELL -/X DEEPEN/_7 RECONDITION /-7 DESTRUCTION /_7 _ <br /> a PUMP INSTALLATION / / PUMP REPAIR -/_7 PUMP REPLACEMENT /_7 Ln . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 55t SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 20 ' j <br /> E � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia, of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casin A <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Pr_oteciion Rotary Type of Grout BenEonite <br /> Disposal Other Other Information ' a y 6wner <br /> Geophysical - Surface Seal Installed By: <br />}; PUMP INSTALLATION: Contractor <br /> .1 Type of Pump H..P. <br /> y' .LACEMENT: / / State Work Ione <br /> PUMPS am:- —/-:/:-.State-Wotk'Done"'_'-T <br /> s <br /> DES.TRUCTIQ Well Diameter Approximate Depth <br /> * � •� scribe Material and Procedure <br /> 11 hereby agree o4hmp3y with all laws and regulations of the San Joaquin Local Health District <br />-and the State of ali`;fo&nia pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion o m ?Work on a new well I will furnish the San-, Joaquin uin Local Health District a <br />,� q <br /> WELL DRILLERS REPORT f,j well and notify them before putting.the..well in.use.... The above <br /> information is true fqxh st -of. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING"AND ; INSPECTION. <br /> SIGNED x`mow -- ' <br /> ---- _ TITLE �'C1 cCCt _. <br /> \�N (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: iy 1G 7K•. "' <br />'j PHASE II GROUT INS; I N PHASE-111_4FAVn INSPECTION <br /> INSPECTION BY r D .. - S"�` INSPECTION BY DATE <br />