Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -To-t- ,7,d-fCE.US : 1601 E. Hazelton Ave: , Stockton, Calif, <br /> ' Telephone: (209) 466--6781 . <br /> APPLICATION FOR WELL CONSTRUGTION OR PUMP PERMIT Permit No. <br /> `I <br /> THIS; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date-Issued <br /> (Complete In Triplicate) . <br /> Application is hereby made to, the -San Joaquin Local Health District fora 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 andAhe Rules and Regul tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1/$ Mile _lorth Hildreth & 1 mile East 99 Frontage CENSUS -TRACT <br /> Owner's Name Doug Edge 1 Phone <br /> Address 53 .7 Hi9dreth' Lane, Stockton, CaTif.'95212 City <br /> Al <br /> Contractor's Name Ross Purvis ce D.ril.lkng, P.O.Hox 285,tinden License # 1.80 2 Phone ' 887-3480 <br /> A. Gal.i . 95236 -- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL,/;F7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTZUTION /x/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /, <br /> F ' <br /> DISTANCE TO NEAREST: "SEPTIC TANK 2001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL —" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial „ i. x Cable Tool Dia, of Well Excavation <br /> X Domestic/private Drilled Dia.' of Well .Casing + <br /> Domestic/public I Driven Gauge' of Casing .12f <br /> Irrigation I Gravel Pack'%_,_Depth of Grout Seal 50' � <br /> Cathodic Protection + Rotary r Type of. Grout T�eet Cement - 1.0 sx mix. <br /> Disposal Ocher„ ; -Other Information ' <br /> Geophysical / r. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ross Purviance Dri?.^ling ' <br /> Type bf Pump _Sul ndraible r t* � H.P. 15 i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL.: Well' Di meter Approximate Depth <br /> � Describe Material and Procedure - - - - <br /> I hereby agree to comply with all laws and reg6laftons' 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„wql-1 and notify them before putting the -well in use. The above <br /> information s . tru t the •best` of. my..knowledge and belief. I WILL CALL FOR' A GROUT INSPECTION <br /> PRIOR TO OU ING D A FINAL INSPECTION. <br /> SIGNED 1 TITLE Omer <br /> DRAW-Ph. T FLAN ON RE E$SE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; ` -4 <br /> G T IN.SPEC ION ` . P _ I/FINAL INSPECTION <br /> INSPECTION BY t,4 DATE $ INSPECTION BY DATE <br /> E H 1426 Rev, 1-74 . <br /> 3/76 2m <br />