Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOLTOFFIECCIE USt: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL• CONSTRUCTION OR PUMP PERMIT Permit No.,3_ A/_ W <br /> --� <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , /- <br /> } (Complete In Triplicate) '�-�S7_z�{,p_ 3(� <br /> Application is hereby made to the San Joaquin Local Health bistrict for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with Sari=Jbaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S.W. KORNER OF WEST RIPON & 'U T.I CENSUS TRACT — <br /> Owner's Name JERRY FISHER ' <br /> � Phone 982_1 <br /> Address 17,747 E e HWY 120 City ' RIPON <br /> Contractor's-Name---REN-N-ING, $ROS.- DRZZLLI-NG,_G4: TC - LLaense_ <br /> #.�-_-4 - 22-P•hone--.522--r,61+�_„_, <br /> Mo W. RUMBLE RD. MODESTO <br /> TYPE'DF WORK (Check): NEW WELL •/V DEEPEN -/—/ RECONDITION -/_' DESTRUCTION %j <br /> PUMP :INSTAUATION / / PLIV REPAIR / / PUMP REPLACEMENT <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS �- <br /> Industrial ± Cable Tool Dia. of Well Excavation 1Qrf 1 <br /> X Domestic/private Drilled Dia. of Well Casing 61c' <br /> Domestic/public r Driven Gauge o£ Casing 12 <br /> GA <br /> Irrigation * Gravel Pack Depth o-• Grout Seal �,0t <br /> Other Rotary Type of.; Grout BENTONITE I <br /> F Other Other Information'SLAB_ BY OWNER i <br /> PUMP INSTALLATION:' Contrictor <br /> . <br /> ' r.._. Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR. � - - - �-- <br /> `. � � � / / State Work Done <br /> .DF.qTRUCTION OF WELL: Well Diameter Approximate Depth**Describe Material and Procedure <br /> I hereby agree' to,.comply with all laws and regulations of the San Joaquin Local Health Distract <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 al <br /> WELL DRILLERS REPORT of.. the well and notify them before putting the well in use. The above <br /> information is true to the be t.,.of my knowledge and belief. { <br /> SIGNED <br /> TITLE <br /> { RAW LOT PLAN ON REVERSE SIDE)11F .� <br /> i <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED -BY _DATE <br /> ADDITIONAL COMMENTS: XV <br /> PRASE-11 GROUT INSPECTION P II N INSPECTION <br /> INSPECTION BY DATEINSPECTI N BY E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H- 1426 <br />