Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. E- 3 73 <br /> ktl <br /> t <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 /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name B. V. Builders Phone59.9-2210 <br /> Address 114 W. Main "�"`+ :'amity' Ripon, Cal <br /> Contractor's Name Hennings I Bros . Drilling Co. ., Inc.' License J90813 Phone 522-1031 <br /> TYPE OF WORK (Check) : NEW WELL -%_7 DEEPEN/_7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR'/ PUMP REPLACEMENT r <br /> Other !/ / — <br /> 4 • <br /> h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES/00 V PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER rJ . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS = <br />. Industrial 10 Cable Tool Dia. of We <br /> ll Excavation 6q <br /> .5/ <br /> � <br /> Domestic/private 1 Drilled Dia. of Well Casing ezvv ( 1 <br /> Domestic./public t4 F Driven --Gauge�of-`Gasiix �" a <br /> Irrigation i Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection _2 Rotary Type of Grout ' PentonlEe <br /> Disposal [ Other Other Information Siab by owner <br /> Geophysical j Surface Seal Installed By <br /> ,. II r <br /> Pim.' INSTALLATION: Contractor <br /> ' T e of Pu <br /> Jk` Yp � � •H.P. <br /> POT REPLACEMENT: / / State Work Done e <br /> PUMP '.REPAIR: .. _— <br /> / / State Work Done <br /> bEsTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material. and Procedure <br /> i I-hereby `agree to' comply with' all laws and regulationsM of the lSan Joaquin Local Health District ; <br /> and the State of California pertaining to or regulating well. 'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 9ROUTING AND A VIN 'INSPECTION, <br /> SIGNS$ <br /> OT PLAN ON REVER IDE <br /> AOR DEPARTMENT USE 0 LY <br /> PHASE -1 <br /> APPLICATION ACCEPTEDBY DATE g-12 9-2� <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PRASEIIl NAL INSPECTION �. <br /> INSPECTION BY -/&-7-> DATE INSPECTION BY OVrl� - DATES'7� <br /> w.;.aIli H <br /> 1426 Rev. 1-74 /71� vqNr t* <br />