Laserfiche WebLink
/ SAN JOAQUTI�c LOCAL HEALTH DISTRICT rl <br /> FOS OFFICE USE: ; 160 . E. Hazelton Ave. , Stockton, Calif. 11 <br /> Telephone: (209) 466-6781 ?E 76-`5`6s-�. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 � <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone '- Zvi-_ a? & Z <br /> Address &AAg City <br /> ., <br /> Contractor's Name License # 12074 Phone g ?Cy <br /> TYPE OF WORK (Check): NEW WELL j& DEEPEN -/_7 RECONDITION /? DESTRUCTION /-'7 <br /> PUMP INSTALLATION f / PUMP REPAIR/? PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _9ff--t^ PIT PRIVY <br /> SEWAGE:DISPOSAL -FIELD-- 'CESSPOOL/SEEPAGE PIT__"` OTHER <br /> PROPERTY LINE - PRIVATE DOMESJIC WELL_. ! '-RUBLIC DOMESTIC WELL <br /> INTENDED' USE ;TYPE OF.'WELL ` � CONSTRUCTION SPECIFICATIONS p <br /> Industrial --- -- Cable Too! ' - Di-a:�of Well Excavation <br /> Domestic/private Drilled _ ._ Dia. of Well Casing )+ t <br /> Domestic/public Driven Gauge of 'Casing _ <br /> Irrigation Gravel Pack Depth of Grout SealCQ&da► t A,j <br /> Cathodic �-- <br /> Protection Rotary Type of Grout �-- <br /> Disposal Other Other Information <br /> Geophysical Stirfa;ce Seal 'Installed 'By: <br /> PUMP INSTALLATIONS <br /> Contractor <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: . f.. ' <br /> ;.State Work Done 4' <br /> PUMP ,REPAIR: State Work Do e <br /> ' - - -- a <br /> DESTRUCTION OF WELL: Well Diame r '� iAPPr' xi td'pth -6 j <br /> Describe Material>and rocs ure �"� < , <br /> I hereby agree to comply with all laws'and regulations oiE t e 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 /> 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 /> SIGNED134A Q&I TITLE <br /> W LOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ..-y.—� <br /> APPLICATION ACCEPTED3Y ofDATE - 1 s-7/ <br /> ADDITIONAL COMMENTS: / �. T <br /> PHASE 1,Tg CRO OSPECTION P I1WAL,14NS?ECTI,0N <br /> INSPECTION EYLZ LATE , G . INSPECTION B TE <br /> F. A 1 A 7 A D__ i_'7 1 /..w <br />