Laserfiche WebLink
!/1601 E.SAN JOAQUIN LOCAL HEALTH <br /> F 0 E FFICE USE: DISTRICT <br /> Hazelton Ave. , Stockton, Calif. <br /> 9 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMITJXPIRES 1 YEAR FROM DATE ISSUED Date Issued /5`76 <br /> I (Complete In Triplicate) <br /> Application is her made to the Sart Joaquin Local Health District for a permit to construct <br /> I� and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the les apd�Re dations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .E CORNER OF TRACY BLVD'. & L•INNE % f CENSUS TRACT v <br /> Owner's Name MIKE AZPIETIA <br /> Phone - ." <br /> Addressi <br /> 2 66 CO L HOLLOW RD_. City TRACY <br /> E <br /> Contractor's Name BENNINGS `BROS. DRILLING CO. INC. License 2908.13 Phone 522-1031 <br /> 2 0 W. HUMBLE RD. MDD ST - <br /> I TYPE OF WORK (Check): NEW WELL � DEEPEN'/� RECONDITION /� DESTRUCTION f7 <br /> PUMP INSTALLATION -/—/ PUMP REPAIR '/ PUMP REPLACEMENT /-7 <br /> Other/ % —~- •. <br /> DISTANCE TO NEAREST: SEPTIC TANKkv SEWER LINES ICO PIT PRIVY X, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'J <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 1111 4�ts <br /> X Domestic/private .1 Drilled Dia. of Well Casing i <br /> Domestic/public I Driven Gauge of Casing 6' <br /> Irrigation <br /> $ Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection X Rotary Type of Grout BENTONITE , <br /> Geophysical <br /> Gical I Other Other Information 'SLAB-- Y OWNER <br /> - <br /> Geo - = <br /> Surface Seal Installed 'B : DRILLER ;I <br /> PUMP INSTALLATION: Contractor I <br /> I <br /> Type of Pump <br /> PUMP REPLACEMENT: /. / State Work Do �� H.P. <br /> � ��� llylv <br /> ne _ �le 0( -, <br /> PUMP '.REPAIR: /� / <br /> - //=5�tate. Work Done _��f( �/ 0-�c�f7`i�i�� tic •-/Gi/1.��� `_ '�..`"' _ <br /> DESTRUCTION OF WELL: Well.. Diameter � �/(1ICi � Approximate <br /> Describe Material and Procedure PP Depth <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 ori a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well ano notify them before putting the.-well, in.use.... .The above <br /> information is true to the-best .o€ My-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A PINAL TNSPECTION. / ��� <br /> SIGNED N . ' NC. B� LL BILE SEC, <br /> 4 DRAW PIAT PLAN 0 . REVERSE SIDE <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COM[MTS:.vAf,3 DATE <br /> =� f'ta�� � r <br /> PHASE II 0 INISPECTI <br /> INSPECTION BY P SE I INAL SP T N <br /> DATE INSPECTION BY <br /> DATE l� <br /> E H MO. _Rev. 1--74 <br />