Laserfiche WebLink
nn SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$ OFFICE USE rL /3-601. E. Hazelton Ave. , ,Stockton, Calif... <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )137P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) �j/ <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 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/LOCATIONe e20,,t 11 ,I � � CENSUS TRACT <br /> Owner's Name Phone A!;Z—21 <br /> Address ,a A <br /> ' <br /> he City <br /> 'C 40,y, <br /> Contractor's Name ive- - R _ y- -LA!!!� License #aK,7 PhoneJ;4eZ 3.q <br /> vi <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> R PUMP INSTALLATION /sem PUMA' REPAIR / / PUMP REPLACEMENT /_7 <br /> E Other / / <br /> I <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY „' e <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 /> Industrial ---Cable Tool f Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing v <br /> -Domestic/public ;;� Driven - Gauge of Casing <br /> Irrigation ;,' Gravel Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary `Type of Grout <br /> .Disposal. Other Other Information 1 <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: ,., Contractor Ac y <br /> ' Type of Pump ,� H.P. 4do <br /> PUMP REPLACEMENT: <br /> / / State Work Done •, <br /> PUMP ,REPAIR: / / State Work Done ` <br /> } <br /> DES•TRUC_TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree-to-comply--with',all�lawsraad 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 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 MD A FINAL INSPECTION. <br /> SIGNED TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I4 GROUT INSPECTION PHAS I_TI/.F NAL INSPECTION` <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> E H 1426 P,Axy i-7L 11/77 2M <br />