Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (203) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermit No. ,71' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issite 7 <br /> (Complete In Triplicate) <br /> Application is 'hereby made to the San Joaquin Local Health District for a permit to con eruct <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 Off Hansen Rd. betweenY©n_S_ds ten, &Hwy 9-01S- CENSUS TRACT 5-3 <br /> Owner's Name Norman A. Codero Phone 415-828-7512 <br /> Address 2891 Springdale bane <br /> City ' San Ramon, Califs <br /> 94583 <br /> Contractor's Name Hgnnin s Bros. Drilli Co. Inc. License #290813 Phone 522-1031 <br /> 2500 W. Rumble Rd. Modesto, a i . <br /> 'TYTE-(3F:-WORK--(-Check-).—NE-W`WEDL—/79"}DEEPEN'1_7--T�RECONDITION�/7TiDES'ZgUCTTOg/ - - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f7 <br /> Other <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 40; 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 12" <br /> X Domestic/private Drilled Dia. of Well Casing __ 6� ' <br /> Domestic/public Driven Gauge of Casing 12 G•a <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by Omer <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '•REPAIR: L7 State Work Done <br /> -:,?ESTRUCTION OF-WELL: Well Dia r. L Approximate Depth y J <br /> Describe-Material and Procedure <br /> r <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 ox regulating well construction. Within FIFTEEN DAYS <br /> 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 shove <br /> information is true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO QROUTING AND A F NAL SPE ION. <br /> IGNE C ,� TITLE �- <br /> W PLOT. PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A <br /> APPLICATION ACCEPT D-BY DATE �� 7 <br /> ADDITIONAL CO ' r <br /> ]? ROUT INSPECTION P II NAL INSPECTION �Y <br /> INSPECTION DATE -3D-7 INSPECTI BY DATE - 5 <br /> µE H 1426..... - Rev. 1=74 <br />