Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �. <br /> Telephoixe: (209) 466-6781 ' r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> A> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,j_/.5-2� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District .for a permit to construct <br /> and/pr-install the work herein described. This application is made in compliance with San'Joaquinf, <br /> County Ordinance No. 1862 and the ,R s and Reg tions f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION --- CENSUS TRACT <br /> a <br /> Owner's Name !L F .v Phone <br /> Address '- C� 3 I n�T T. CT-�fCJIT�In/Eltz Jz D City ,A-C-PkM pC) <br /> Contractor's Name SAN dOUflY PUTS �Md License #_7/03700"Phone <br /> TYPE OF WORK.. (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES ,,.-PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE' PIT OTHER <br /> PROPERTY LINE -µ 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 Sealer <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br />' PUMP INSTALLATION: Contractor �i�1�J �T _ Jrar <br /> Type of Pump H.P. C� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP EPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 GROUTING FINAL INSP&CZ <br /> SIGNED TITLE _ I(111(.TFinT nrr �.pp��.,,., . <br /> (PMW PLOT PLAN ON REVERSE SIDE) I ulyff bURI <br /> FOR DEPARTMENT USE ONLY • Vj le ffeef <br /> PHASE I � P. Q. Bax 20I <br /> APPLICATION ACCEPTED BY ",DftT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �� DATE <br /> E H 1426 RPv. . 1-7A <br /> n/77 _ 2M <br />