Laserfiche WebLink
�,,,,�y/ 6 /q <br /> SAN JOAQUIN rOCAI,._HEALTH DISTRICT Com"" I <br /> _ :ICE USE: ' 2601 E. Hazelton Ave. , ,Stockton, Calif. 0;4,�6k <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> • i <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued <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 /> I� JOB ADDRESS/LOCATIONAIRPORT l WAY & NILE AVE° OPPOSITE NILE DOWN CENSUS TRACT <br /> k: <br /> DIRT LAVE T OF <br /> Owner's Name MARTIN PALMER AIRPOR WAY Phone 823-3082 <br /> I Address 1+09 E. NILEAVE. City <br /> MANTE CA <br /> Contractor's Name HENNINGS BROS. DRILLING CO-. jINC. License # .290813Pbone 522-1031 <br /> h RUMBLE RD. MOD-.' <br /> TYPE OF WORK (Check): NEW WELL /x-7 DEEPEN /7 RECONDITION /7 DESTRUCTION /"7 <br /> PUMP .INSTALLATION / ] PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Otherl / / <br /> DISTANCE TO NEAREST: SEPTIC'TANK + SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER(� LL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IN ENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r.� <br /> Domestic/private 7. Drilled Dia. of Well Casing is <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation ,� # � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection w I.Z Rotary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical 1 Surface Seal Installed B ., <br /> PUMP INSTALLATION; Contractor <br /> - Type of Pump H.P. <br /> `*rPUMP REPLACEMENT: /�/ State Work'Done <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 'istrict. <br /> and the State of California pertaining to ox regulating well"constru .6tion. Within FIFTEEN DAl�S <br /> i after completion of my 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 .af my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> uPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED.1%NNINGA BROS. DRILLIN G C INC.- BY TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE lDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:, <br /> PHASE II GROUTtINSPECT 0 PHASE I I/FlN INS. ECTION <br /> INSFECION BY iDATE INSPECTION BY / .DATE $- <br /> X26 R v. =74 Ohs G�� � �/������ �;.v: ,�� �� �� d77 � _ <br />