Laserfiche WebLink
1 SAN JOAQUIN LOCAL HEALTH DISTRICT 4j- `l <br /> 'F—OF Ot FICE USE: 1604 ,. Hazelton Ave. , Stockton, Ca?'_i�\. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � 7J <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 10663 N.Alig hway 88 CENSUS TRACT <br /> Owner's Name Jesse and Aileen Souza phone 931-0391 <br /> Address - .10663 N. Highway 88 City <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License #290813 Phone545-1185 <br /> TYPE OF WORK (Check) : NEW WELL �/ DEEPEN /—/ RECONDITION I_1 DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR _/_/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAG8 PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL —_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 26" <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing gauge <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout none <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump __ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws andregulations 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 puttingthewell in use... The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> . RIOR TO G OUTING AND A FINAL INSPECTION. <br /> SIGNED TITL]Driller <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I 4 <br /> 0PLICATION ACCEPTED BY DATE �7 �� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY J` DATE <br /> E H 1426 Rev. . 1-74 t/77 2M <br />