Laserfiche WebLink
r <br /> f k <br /> -1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> ! Telephone: ­i,(2M 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5`-3.S'-l" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete in Triplicate) <br /> Application is hereby made tti the San Joaquin Local health District 'for a <br /> and/or install, the work herein described. permit to construct <br /> 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 <br /> JOB ADDRESSAOCATION 19533 E. Highway 120 - 1st place east. ofr ENS1I,g RACT <br /> . nwy 12� <br /> Owner's Name Bud E. Rod oani Phone 838-2613 <br /> Address 19909 E. HwyI120 City Esc lan Calif <br /> a . <br /> Contractor's Name Hennings ! Bros . Drilling Coo' , Inc. ' License -0-90813 Phone 522-1031 <br /> West um e RU. =0eS uu , UaTTf. 9535 <br /> TYPE OF WORK (Check): NEW WELL/?{ DEEPEN j-7 RECONDITION / DESTRUCTION f7 <br /> PUMP INSTALLATION /� PUMP REPAIR -/-7—pump REPLACEMENT /? (/1 <br /> Others <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER 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 11't i <br /> Domestic/private t Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing12 !Ga <br /> Irrigation Gravel Pack. Depth of Grout Seel. pt. <br /> Cathodic Protection `x =0=Type of Grout Bentonite k <br /> Disposal - -Other Other Information 1a3� owner -- <br /> _ Geophysical i Surface Seal Installed By: rt.L.rS <br /> PUMP INSTALLATION: Contradtor r ' <br /> Type of Pump Y H.P. <br /> PUMP REPLACEMENT:., <br /> ,. / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter <br /> 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 ci$mpletion 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-of. my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. -- <br /> SIGNED r f TITLEZr,eP <br /> (DRAW PLOT PLAN ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATES <br /> ADDITIONAL COMMENTS; .�. <br /> PHASE II GROUT INSPECTION / PHASE III JFINAL INSPECTION <br /> INSPECTION BY� DATE 1 2- -7.7 INSPECTION By DATE Y-7J-;b <br /> , <br /> :.E K 1426Re . <br /> v. 1-74 r ' 1 /nr naw <br />