Laserfiche WebLink
SAN JOAQUIN LOCQ.L,HEALTH DISTRICT <br /> EOE OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, F ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> ' (Complete -In Triplicate) <br /> Application is tereby 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2,��� L��IC��� �� r CENSUS TRACT. <br /> Owner's Name �y-(� � �yY) - Phone ` <br /> Address � (� _ C'i9.�/m }✓/ /� - City .i�C m <br /> Contractor's Name A141_�Z !�JlT � �/�/C��/11�i License # hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION DESTRUCTION /_7 <br /> r PUMP)'INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO;NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />'F SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER- <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL Z42 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 ,t6_0 )C�7, <br /> j Cathodic Protection Rotary Type of Grouter _' ,F <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br />� PUMP INSTALLATION: Contractor <br /> Type of Pump ��i`,.�'/Y7E �,. VZ�E7~ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> IPUMP .REPAIR: y / /"'`S'tate Work Done <br /> DES-TRUCTIONOF WELL: Well Diameter " 7Approximate Depth <br /> Describe Material and Procedure <br /> iI hereby agree to comply with all laws and regulations of the San Joa4uiri_'1oca1 Health District <br /> land the State of California pertaining to or regulating well..'cons.tructien. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin. Local­HeaTth 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 a , my knowledge and belief. I WILL -CALL FaR_A GROUT. `INSPECTION <br /> PRIOR TO GROUT D F PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> �� -- FOR DEPARTMENT USE ONLY <br /> t PHASE I J �] <br /> APPLICATION :ACCEPTED BY DATE <br /> , ADDITIONAL COMMENTS: <br /> °"PHASE` Il GROUT-xNSPECfiTfIN- _ w��.....- PHASE T1T%FINAr 'INSPECTION <br /> f INSPECTION BY. DATE ''' '-�•-'1` `INSPECTION BY r�. ,/ DATE 7-.4 ��` � <br /> €. .. I <br /> _" P. u 1119A ico r- 7-7G _ ��7 1 � ` <br />