Laserfiche WebLink
r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, - =;�_ - i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED, Date Issued//—//,,71 <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]lherein 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.l� <br /> JOB ADDRESS/LOCATION 906 West Howard Rd. Stockton Union Is lana CENSUS TRACT <br /> df: <br /> Owner's Name. August $azzanti Phone .465--$636 <br /> Cal. <br /> Address .. - 496 Viet Highway. _- City 'Stockton, <br /> IL 290$l3 52.2-1031 <br /> Contractor's Name Hennings Bros . ]rilling Co. , Inc: e # Phone <br /> TYPE OF WORK (Check): I9EW WELL DEEPEN '/7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /140 CESSPOOL/SEEPAGE PI OTHER / <br /> PROPERTY LINERIVATE DOMESTIC WELL"4;8t' PUBLIC DOMESTIC WELL r <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I ,121t- <br /> Industrial Cable Tool Dia. of Well Excavation } <br /> XX Domestic/private ' Drilled Dia. of Well Casing $�? <br /> Domestic/public Driven Gauge of Casing _ 160W Plastic_ <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ? <br /> Cathodic Protection Rotary Type of Grout he ` ftp <br /> Disposal `I Other Other Information Slab by owner <br /> Geophysical Surface Seal Itistalled B : 'driller <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 /> T 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 .regul.ating.well '-construction. Within FIFTEEN DAYS <br /> after completion of my ' ork 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 WTLL CALL FOR A ,GROUT INSP CTION' <br /> PRIOR TO GROUTING AND A!PINAL INSPECTION. B ` ��,✓ <br /> SIGNED HEN NINGS BROS . C . , INC. T <br /> ip (DRAW PLOT PLAN ON REVERSE SIDE <br /> SDR DEPARTMENT USE ONLY <br /> PHASE.'I ' <br /> APPLICATION ACCEPTED BY DATE �L�J <br /> ADDITIONAL COMMENTS: ,IN <br /> PHASE II GROUT INSPECTION P F NAL INSPECTION <br /> INSPECTION BY . .ill DATE _-- INSPECTION XT DATE <br /> L---.E H 1426 Rev. 1-74 h, - <br />