Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V4 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )6-_3,3-7A) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,1- ,?--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 Rules al.dI s f W oaquin Local Health District. <br /> Z � k AISI . <br /> JOB ADDRESS/LOCATION TWO RIVERS RD.-- 30745 TWO RIVERS RD. CENSUS TRACT <br /> RIVER JUNCTION VINEYARDS <br /> Owner's Name C/O RON VELLA Phone 545-1222 <br /> Address P. 0. BOX 1228 City OAKDALE, CALIF. <br /> Contractor's Name HENNINGS BROS . DRILLING CO. INC. License # 290$13 Phone522'-1031 <br /> . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /11 DEEPEN '/—/ RECONDITTON /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES .. .:, PIT PRIVY it•-,6=�{� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 24" <br /> Domestic/private Drilled Dia. of Well Casing 67 <br /> Domestic/public Driven Gauge of Casing a G� <br /> XX Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Slab by oyyrra.,g j! <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work D ne <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED O . , INC. TITLE <br /> D16AW PV T PLAN ON REVERSE SIDE SE y <br /> R DEPAR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .0 DATE G <br /> ADDITIONAL COMMENTS: <br /> PHASE TZ GR U INSPECTION Y. PHASE /FIN INSPECTION <br /> INSPECTION BY Aj TE INSPECTION BY DATE'? - <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />