Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�rOFF'ICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77,Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $� <br /> (Complete <br /> Application is hereby made to the SanJoaquin i.cal 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 t e San Joaquin Local Health District. <br /> �2-r-z-s C lr,"I+ Mile South of Copperoplis and - mile t g-3-30a_0.� <br /> JOB ADDRESS/LOCATIONWest of Hewitt Rd* CENSUS TRACT <br /> Owner's Name R & J Dondero Phone <br /> Address _ 16299 Ni HWY 26 City Linden <br /> Contractor's Name PUrViance Driller License #21+0107 Phone 931-"8 <br /> TYPE OF WORK (Check): /NEW WELL /? DEEPEN _ <br /> /'� RECONDITION /-X7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> none SEWAGE DISPOSAL FIELp CESSPOOL/SEEPAGE PIT OAR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INT'ENDE` D 7gE TYPE OFWELL CONSTRUCTION SPEC-L ATIONS <br /> Industrial XX Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP / / State Work Done <br /> PW :REPAIR: / / State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -----� <br /> I hereby agree to comply with all laws and regulationslof the San Joaquin Local Health District <br /> and the State of California pertaining to or regulat,inj 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 INSPECTION <br /> PRIOR TOG UTING D FINAL INSPECTION. <br /> SIGNED <br /> TITLE partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 9M <br />