Laserfiche WebLink
SAN JOAQUIN LOCAL. PEALTA. DISTRICT i <br /> FOE OFFICE FTSE- _ 1601 E: Hazelton Ave. , Stockton; Calif. <br /> Telephone (205) 466-6781 7$-q8 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP` PERMIT Periuit No: <br /> THIS PERMIT EXPIRES 1,YEAR'FROM DATE ISSUED Date Issued <br /> - (Complete In Triplicate) <br /> Application is lierety made to the- San .7oiquinLocal Health District. for. a permit tocans'truict <br /> and/or install the' wdik herein described. This application is made ii; compliance with' San Joaquin <br /> County Ordinance No i8'62 and the Rules and Regulations of the 'San Joaquin Local Hea'Tth' District:• <br /> .SOB AbDRESS/LOCATION 1.7200 E. Hwyr 26( 200' South Hv 26 & l00' gest CENSUS TRACT <br /> Archerdale ea -e <br /> bwner's Name Earl Snyder = Phone � <br /> Address 1-7200 Cit E H . 36 <br /> - - x2_4 T�inolen, Ca...if952,.._._ <br /> Contractor's Name.:x urv'iance Drillers P.O.Box 64 Linden Calif. License # 240207 . Phone'.931,:4A68.. <br /> - 95236 <br /> i <br /> TYPE OF WORK (Check).- NEW WELL /x/ DEEPEN / / RECONDITION /_7 DESTRUCTION /7 _ <br /> - f PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> r-.. Other <br /> - - __ <br /> DISTANCE TO NEAREST: SEPTIC.-TANK—'x.20 --SEWER_LINES_ _�` PITrPRIVY <br /> SEWAGE DISPOSAL FIELD ]_201 CESSPOOL/SEEPAGE'PIT QTHER -' <br /> PROPERTY LINE -• PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDi.USE TYPEmOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X , Cable Tool Dia. of Well Excavation sit <br /> F:K .Domestic imp riva:te =F Drilled Dia. of We11 Casing 8" ,. O <br /> Domestic%pubiic' ;"Driven Gauge of Casing 30 <br /> Irrigation Gravel Pack Depth, of Grout Seal 50' <br /> Cathodic Protection Rotary Type of Grout 2 part sand �_ part cement <br /> t Disposal Other -Other Iiformationm <br /> Geophysical: Surface Seal Installed By: <br /> PUMP INSTALLA'ION!i i; r <br /> contactor <br /> Type of 'Pump' m H,P <br /> PUMP REPLACEMENT. : /7 State Work Done <br /> PUMP .REPAIRt / % State .Work Done E <br /> DES,TRmUkfi0N OF WELL Weil Dianietdr .- ----•--- Apprbi iinate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with .all'%laws and regulations of the San Joaquin Local Health District t <br /> and the State of California pertaining to or 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 above <br /> information is true to the best of: my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A FI AL INSPECTION. <br /> SIGNED TITLE <br /> DRAW:Ph T PLAN` ON.REVERSE SIDE ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I IAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 3-Z -7� <br /> PF V <br /> E H 1426 Rev. '1-74 ', <br /> 3/76 2M <br />