Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: 1601E Hazelton 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 San Joaquin Local health District for a permit to construct <br /> and/or instal, 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 Jbaquin Local Health District. <br /> .TOB ADDRESS/LOCATION . Between Peach & Fig on. West Side UAt,_G u CENSUS TRACT' <br /> Owner's Name Vernon Sha Phone ' $23'3632 <br /> Address 21375„ Union. Rd. City lAanteca, Cal <br /> Contractor's Name Fos . Drilling Co. , lnc.. . License # .290813 Phone 522-1031. <br /> res{ um e o, 97. 95350: <br /> TYPE OF WORK (Check) : NEW WLLL XV DEEPEN J7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION/ j PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other [/_7 ' <br /> Nle _. <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 , SEWER LINES 730 t PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL.:_ZQ ' PUBLIC DOMESTIC WELL r\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� <br /> Industrial i Cable Tool. Dia. of Well Excavation ll'T trV <br /> _ X Domestic/private I A Drilled Dia. of Well Casing _ n <br /> Domestic/public Driven Gauge of Casing 12 Gs. <br /> Irrigation i Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Pr_otec.tion i X . 'Rotary Type of Grout Bentonite <br /> Disposal } Other Other Information slabt slabby owner <br /> Geophysical Surface Seal Installed :By: driler <br /> PUMP INSTALLATION: Contractor. <br /> Type ,o' PURT7 H.P. <br /> PUMP REPLACEMENT.- .11 / / State' Work Done;- , <br /> TIM ,,REPAIR: / / State Work Done <br /> DES=TRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationsaof the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'cbnstructioa. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will- furnish the San Joaquin Local Health District't' „ <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 beliefq I WILD, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL�INSPECTION. By. <br /> SIGNED Hennit s Bros . bre in —Co. , Inc. TITLE <br /> y• DRAW PLOT PLAN ON REVERSE SIDE <br /> ! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' tD-00-W, <br /> ADDITIONAL COMMENTS; -- <br /> E I GROUT INSPECT ON PHAS19JI19FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE \=4 <br /> E H 1426 Rev. •1-7G 3u <br />