Laserfiche WebLink
�)O lie- <br /> S�" JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: �T 1601 Hazelton Ave. , Stockton, Cal. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79-1h, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued rf_ -.3�-�9 <br /> (Complete In Triplicate) <br /> Application 1s 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•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 Stoneridge L„ ZJ CENSUS TRACT <br /> y <br /> Owner's Name Don rose <br /> Phone R3Fi-n422 0. <br /> Address P. 0. Box 326 City Tracy <br /> Contractor's Name Hennings Brothers License 4 C57 Phone ' 545-1185 <br /> • 99nR13 ^` <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN/7' RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 0� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWS S PIT PRIVY 1 <br /> SEWAGE DISPO FIELDCESSPOOL/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 11" - 12" <br /> X _ Domestic/private ' j x Drilled . Dia. of Well Casing 6" <br /> Domestic/public Driven Gauge of Casing pyr Irn <br /> Irrigation ;GFavel Pack Depth of Grout Seal 50' <br /> Cathodic Protection Rptar' Type of Grout Concrete <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: Fritas <br /> PUMP INSTALLATION: Contractor A Fritas Electric <br /> Type of Pump .Jet Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7„State Work Done <br /> DESTRUCTION OF WELL: Well'DiameterApproximate Depth <br /> Describa Material and Proce4ure <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 FITrEKK DAYS <br /> after completion of my Bork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well apd'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 TR GROUTING AND A FINAL INSPECTION.1, <br /> SIGNED ��y \� ( >R`.. TITLE ]/• f <br /> .� '?� S'n 1 Lir r A <br /> (�✓ TDRAW-P 1�” PLAN -ON REVERSE SIM) <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY F DATE � 0'-� <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT iN ECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E 9 1426 Rev. 1-74 3/76 2M <br />