Laserfiche WebLink
% <br /> r "a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ,..+° 1601 E. Hazelton Ave. , Stockton, Calif. <br /> / 4 Telephone: (209) 466--6781 <br /> e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS.-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) oS'-3so_/ <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 Ordnance No. 1862 andl,the ales and Regulations of the San Joaquin Local Health District. - <br /> JOB ADDRESS/LO ION `� I CENSUS TRACT <br /> Owner's Name "`" / <br /> PhoneZ / <br /> Address sj� <br /> City <br /> HENNINIG, &ROS. DRILLING Co., INCs <br /> Contractor's Name I I <br /> O D License # Phone <br /> 2500 W. RUMBLE- *� <br /> t-ALIF <br /> . k <br /> TYPE OF WORK (Check) : NEW WELL 1 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTAL TION / / PUMP REPAIR _/_/ PUMP REPLACEMENT /_7 <br /> Other / / r — <br /> DISTANCE TO NEAREST: SEPTIC TANK D . f SEWER LINES &/ PIT PRIVY j I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r/ OTHER <br /> � r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />_ Industrial Cable Tool Dia. of Well. Excavation <br /> Lam'Domestic/private e,—'Drilled' Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y H.P. — ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ! <br /> State Work Done <br /> DESTRUCTION OF •WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />[ 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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> CnformatffpRN4G�WrDtooR ha jt INC;, y knowledge and belief. <br /> SIGNED 2500 dle TITLE <br /> MO (D W LOT PLAN ON REVERSE SIDE) <br /> Y <br /> FOR DEPARTMENT USE ONLY <br />'HASE I <br /> LPPLICATION ACCEPTED BY / DATE �- _7�3 <br /> IDDITIONAL COMMENTS: <br /> _ - - <br /> PHASE I ROUT INSPECTION PHAS I I FINAL INSPECTION <br /> NSPECTION BY DATE <br /> ._ _ 3-�3 INSPECTION BY / r DATE � +-��' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />