Laserfiche WebLink
tA SAN JOAQUIN LOCAL HEALTH DISTR= ! <br /> FOTO OFFICE USE.-' 1601 E. Hazelton Ave. , Stockton, Calif. p1jf <br /> Telephone: (209) 466--6781 t-4- " <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES , 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 mode 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 600' oacco 'tea_ =& .6 Mile East Duncan &i. CENSUS TRACT lOS co��s <br /> Owner's Name V & A Lagorio Phone <br /> Address 1.8601 Tobacco Road, Linden, Calif 952.3. City ' <br /> Contractor's Name Purv'iance Drillers,P.O.Box 641Lindea,Calffo License # '2401-07 Phone 931-4468 <br /> . 95236 <br />'TYPE -OF WORK (Chedk)i` +NEW-WELI�`/-7- 'OEEPEK'/a TRECONDITION�I_ =DESTRUCTION /-7 <br /> :PUMP INSTALLATION /5r/ PUMP REPAIR -/-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 600' - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 600' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT," PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial aCable Tool Dia. of Well Excavation Existing 1.40 <br /> Domestic/private Drilled Dia. of Well Casing Inst. 1211 T. ner <br /> Domestic/public Driven Gauge of Casing 10 <br /> -x _sT rigatian Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i _ Other Other Information ' <br /> Geophysical --� Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor `: D - �er <br /> Type of Pump ~"�Tukhjj . .. �.� H.P. 50 <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR:_ / / - State Work Done _'• ' <br /> DESTRUCTION OF WELL: r Well Diameter 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 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 /> l information is true to-the-best-of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> JPRIOR TO GROUTING AND A. PINAL INSPECTION. <br />',SIGNED i TITLE p <br /> aAgar <br /> f (DRAW PLOT PLAN, ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> DATE <br />` ADDITIONAL COMMENTS: �.< <br /> 'PHASE T GROUT INSPECTION Y PHASE III/FINAL INSPECTION - <br /> INSPECTION BY DATE YNSPECTION BY DATE -- <br /> ':i�—Siad/ 1"-t.;+1' -64 <br /> l b u I L'Ic -n, 1.I?c 9M <br />