Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOg�'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-5181 17 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /c <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 640' North, of Milton Rd. & 1.1 IyIiZe Brest of Duncan CENSUS TRACT <br /> Owner's Name -- lialry Eilers Phone <br /> Address 16657 E. Wilton Roadi Linden Calif. 95236 City <br /> Contractor's Name Furviance Drillers, Box 64, linden, Cal if. License # 240107 Phone 931-4468 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN 17 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/-7-pump REPLACEMENT 2L <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE14ER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> 'Domestic/private Drilled Dia, of Well Caning <br /> v <br /> ' Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work Done Re-install 50 HP Turbine Pum <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of1my work 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 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPECTION. <br /> SIGNED I TITLE <br /> (DRAW Fyn PLAN ON REVERSE SIDE <br /> PHASE I ORi EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY D AXE - <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GR¢ 199PECtION PHAS I NSPECTION <br /> INSPECTION BY ATE INSPECTION BY ATE - - <br /> E H 1426 Rev. 1-74 �t/ 2M <br />