Laserfiche WebLink
� SAN JOAQUIV LOCAL HEALTH DISTRICT <br /> POFs`fl�'FICE USE: � e y <, <br /> 1601 E. ;iazelion Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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) <br />' Application is hereby made to the Sat: 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 Ordinance No. 3862 and the Rules and Regulations of the $an Joaquin Local Health District. <br />?AJbB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Occidental Chemical Company <br /> Phone 858-2511 Ext.324 <br /> C o Bob Edson- <br /> Address P. 0. Box 198Citq - Lathrop, Cal. <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc.: 2.90$13 522-1031 <br /> License. { � Phone <br /> TYPE OF WORK (Check): NEW WELL 'L7 DEEPEN '/_7 RECONDITION _ x <br /> T DESTRUCTION 2 r�/F�L 5 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES '_P PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL �- OTHER <br /> .`INTENDED USE TYPE OF WELLCONS <br /> PUBLIC DOMESTIC WELL <br /> ., CONSRUCTION SPECIFICATIONS <br /> Industrial; __ Cable Tool Dia. .of We31 Excavation <br /> Do stic/private ,; Drilled Dia. of Well Casing <br /> w <br /> Domestic/public "Driven Gauge of Casing <br /> irrigation . . 8 <br /> I Depth of Grout Seal <br /> Cathodic Protection Rdt�ar `--* <br /> *. <br /> Dis osal -y '�'YPe of Grout <br /> p :i 's-. . <br /> GeophysicalOther _ . Other.,Information <br /> Surface•5eal-lnstalled 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump F <br /> H.P. <br /> PUMP—REP'LACEMENT: <br /> /-/ -S'tate"Woik-Done •.:�_< ; <br /> PUMP '.REPAIR: / / State Work Done <br /> - F <br /> DESTRUCTION OF WELL:- Well Diameter 12" - 6r Deep 10"--150 t % r <br /> Describe Material and Procedure ement ea poximate Depth ; -'. <br /> - o 7`r '— R} <br /> I hereby agree to comply with all laws and re ati ns of the San Joaquin Local Health District' <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYSA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> aELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.. . The above <br /> Information is true to the ..Well my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO ROUTING -AND A FINAL INSPECTIQN. <br /> SIGN D HEN CO. <br /> INC. c ' <br /> TITLE <br /> DRAW PLdT PLAN ON REVERSE SIDE - <br />'RASE I FOR DEPARTMENT USE ONLY f <br />►PP IL CATION ACCEPTED BY ik lA (� /--3_-7Z <br /> MDITIONAL COMMENTS: DATE , <br /> PHASE Il GROUT INSPECTION <br /> INSPECTION PHASE II F SPECTION2r`� <br /> BY DATE INSPECTION BY G,v DATE /- <br /> E H 1426 <br /> Rev. 1-74 ' r <br />