Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFY;OFFICE USE: �v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1d <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE :ISSUED Date Issued J/--5--7� <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 madeAn compliance, with. San Joaquin <br /> County Ordinance No. 1862 and the Rules .and Regulatfons .of the. San Joaquin Local Health .District. <br /> .TOE ADDRESS/LOCATION I CENSUS TRACT, j <br /> Owner's Name -ARENT SCHILDER Phone 599-3397 <br /> Address 19511 S. _WILLIAMS, WAY City . " RIPON' k <br /> Contractor's Name _HENNINGS BROS. DRILLING CO.1 INC. License #290813 Phone 522-1031 � <br /> _ - MOD..,... . . <br /> TYPE OF WORK (Check): NEW WELL /$7 DEEPEN '/_7 RECONDITION / j DESTRUCTION /7 ' <br /> PUMP INSTALLATION Cl- PUMP REPAIR/-7—PUMP REPLACEMENT 17 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SSR LINES PIT PRIVY,_„ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria], Cable Tool Dia. of Well Excavation 1111 <br /> Domestic/private Drilled Dia. of Well Casing 6-5/81' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation : Gravel Pack- Depth of Grout Seal 5Q r, <br /> Cathodic Protection R Rotary Type of Grout , <br /> Disposal Other Other Information ' Slab. by, ,fpr <br /> Geophysical Surface Seal Installed By* driller <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP,:REPAIR: /7 :State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> De tribe Material a d Proce uregaze <br /> I hereby agree to comply with al laws and regulations of the Aan Joaquin Local Health District <br /> And the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED. HENNINGS BROS. DRILLING C INC . BY TITLE SEC. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATEJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION r� <br /> INSPECTION BY RATE �t ), ,b INSPECTION BY _ - DATE <br /> H 1G2�". .- Qo<.` i_7i 1./?t' mut <br />