Laserfiche WebLink
SAN JOAQUIN LGGAIr HEALTH DISTRICT <br />FOfi OVFICE U— SE T �`�'rr 1601 E. Hazelton Ave., Stockton, Calif. <br />°t�J7 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 _a�, -� <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 herein described. This application is made in compliance with San Joaqu <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br />JOB ADDRESS/LOCATION Lathrop Rd.» -7001 West of Cottage Rd. 4 *D-gthCENSUS TRACT <br />- � side <br />Owner's Name A. S-Pandrio Phone 2�9-2 04 <br />Address 7272 E .:1 La throe:- Rd. City _. Mame n <br />Contractor's Name 'Hennings Bros. Drill trig Co.,Inc. License # 29081 Phone 522-1 Q31 <br />2500 w1 Rumble Rd., Mad. __— <br />TYPE OF WORK (Check): NEW WELL /x DEEPEN / / RECONDITION /_% DESTRUCTION /^% <br />PUMP INSTALLATION / % PUMP REPAIR / / PUMP REPLACEMENT I-7 <br />Other <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES; PIT PRIVY <br />SEWAGE DISPOSAL FIELD _je+ ,CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br />Industrial Cable Tool Dia. of Well Excavation jjn <br />Domestic/private Drilled Dia. of Well Casing 6-5/811 <br />_ Domestic/public Driven Gauge of Casing- 1 �A <br />Irrigation Gravel Pack Depth of Grout Seal 50= <br />Cathodic Protection X Rotary Type of Grout _ Bent O ite <br />Disposal Other Other Information Slab --by. owner <br />Geophysical Surface Seal Installed By: dr it <br />UMP INSTALLATION: Contractor 61N��/L <br />-_—� Type of Pump - H.P. r <br />PUMP REPLACEMENT: / /� State Work Done <br />r <br />PUMP.REPAIR: / / State Work Done <br />i <br />DESTRUCTION OF WELL: Well Diameter �2yyt ° : Approxgfmate Depth 0 <br />C, � Desc ibe Material an rocedure <br />I hereby agree to comply with all laws an egu ions o the an oa uin Local Health District <br />and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAY: <br />after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br />WELL DRILLERS REPORT of the well and notify them before putting the.well in use. The above <br />information is true to thel.best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOt <br />PRIOR TO GROUTING AND A FINAL INSPECTION. INC. B� TITLE SEC <br />SIGNED • <br />PrVDRAW..PLbT PLAN ON REVERSE SIDE <br />F DEPARTMENT USE ONLY f <br />-RASE I 1 <br />!PLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHAS I GR INSPECTION <br />INSPECTION BY DATE 9-1(-76 <br />E H 1426 Rev. 1-74 <br />DATE <br />PHASE I /FIN INSPECTIO <br />INSPECTION BY DATE <br />7b <br />