Laserfiche WebLink
O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :OFFICE USE: 1601 E. Hazelton Ave. , . Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM� DATE ISSUED <br /> f Date Issued(Complete In. Triplicate) <br /> Application is hereby made to the Sun Joaquin Local I3ealth 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 N6.1862 and the Rules and Regulations of the San Joaquin Local Health District. # <br /> #f��SQ /✓ L7'I�G(G 7Z)nJE ��F.�t <br /> JOB ADDRESS/LOCATION � r� <br /> 20 S. Harney Lane & 2251 <br /> E. Jack Tone Road , CENSUS TRACT <br /> I <br /> Owner's Name Bog igno Brost <br /> i Phone <br /> Address - 7899 N. Demartini Lane, Linden, Calif, . .F` $ <br /> City <br /> Contractor's Name,I'ur' viance Drillers, Box 64, linden, C 7 if'. License # -24:01.07931.- 68 <br /> Phone 44 f <br /> TYPE OF WORK (Check): -NEW-WELL`/�- DEEPEN /7` RECONDITION"J - DESTRUCT ION � <br /> PUMP INSTALLATION / PUMP REPAIR /_7 pump.REPLACEMENT 17- Other -/ / <br /> DISTANCE TO NEAREST: SEPTIC -TANK 100' SEWER LINES PIT PR <br /> SEWAGE DISPOSAL FIELD IVY � <br /> CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL `� <br /> INTENDED USE TYPE OF WELL".-; CONSTRU,CTION-_SPECIFICATION5 <br /> Industrial <br /> x ;w <br /> - Cable Tool Dia.'of Well Excavation <br /> Domestic/private 1. Drilled Dia. of Well Casing gn T� <br /> ___x__ Domestic/public � DrivenGauge of Casing , O <br /> Irrigation w + y.Gravel Pack Depth of Grout Seal <br /> Cathodic Protection s Rotary Type of Grout <br /> Disposal i Othernea=t cement <br />-Geophysical Other Information <br /> Surface -seal Installed By:-,. 77 �. <br /> PUMP INSTALLATION: Contractor Puir iifice Dri?_j_eis <br /> r ., <br /> Type ofj rump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done s <br /> / <br /> PUMP '.REPAIR: / State Work Donee 1 <br /> DESTRUCTION OF WELL: Well-Diameter <br /> Describe Material. and Procedure Approximate Depth <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 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 /> Lnformation is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT <br />'RIOR TO GROUTIN A FINAL INSPECTION. INSPECTION <br /> 3IGNED' kt <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATiON <br /> ACCEPTED BY BY 0 <br /> 1DDITIONAL COMMENTS: F DATE : <br /> PHASE II GROUT INSPECTION <br />:NSPECTION BYPHASE III FINAL INSPECTION <br /> DATE t-z6 INSPECTION BY <br /> E H 1426 Rev. 1_74 _ n <br />