Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "FOR"OFFICE USE: 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone : (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7&Iff <br /> THIS PERMIT EXPIRES 1 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 made in compliance. with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r_"1 (fog9 S. c11 >1116�-t-"` Hcaly 2C`7 3-I C-4 k <br /> JOB 'ADDRESS/LOCATION 4L Mtn 11 T2Cc Q CENSUS TRACT <br /> Own er's Name 0a k n c oA.1 ��S'�ic ]' Phone 3 I¢ <br /> Address <br /> � T�� 5'�!T-r rT •...,..,. ..,. ,_...__._ City 0 � <br /> Contractor's Name & r e„_ _ License ,��,��S )�, / PhoneJ <br /> if V <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /7 I <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other / / _W <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER 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 /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 r Other Information <br /> Geophysical • Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor &,v'Prl!rnf oti C <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:- / / State Work Done 4K/4L_ <br /> DESTRUCTION OF WELL: Well Diameter f Approximate Depth <br /> Describe Material dtid Procddure _ <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 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 GROUTIN5 AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE &14_2_Z-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II/F AL INSPECTION <br /> INSPECTION BDATEY <br /> INSPECTION BY DATE <br /> (l/ 6/ 7 7 <br /> 26 77 <br /> Pm <br />