Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT A!L 10 <br /> FJDR OFFICE USE: �' 1601 E. Hazelton Ave. , Stockton, Calif. yr1 , <br /> Telephone: (209) 466-6781 feO u/'"P� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:.Z7-$34 ' <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 /> ,JOB ADDRESS/LOCATION S 5��/ / .�. CENSUS TRACT i <br /> iI <br /> Owner's Naive a 2 Phone j � - 3 �1_3 C <br /> 'Address r Q. City / T <br /> Contractor's Name1t�. 1(� ('t Z :[ 1 ND C_. OT License #3nb 326 Phone 4,3,2-4 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPVNIf RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? � <br /> Other / / ' V <br /> DISTANCE TO NEAREST: SEPTIC TANK .�O— SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER I <br /> PROPERTY LINE 9�d PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ZIndustrial Cable Tool Dia. of Well E-kcavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dome stic./p'ub].ic'- Driven Gauge of Casing <br /> Irrigation ✓ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary-. Type of Grout Opti _e _ <br /> Disposal Other Other Information <br /> Geophysical T Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpc��_tis �2 t ��/ H.P. <br />!k PUMP REPLACEMENT: / / State Work Done <br /> r PUMP .REPATR: / / State Work Done r <br /> ,:..a -_ - ,...•.-i a-q. : ^mss•� <br /> k DESTRUCTION OF WELL:- Wel-l-D. meter [ Approximate Depth 2c7 <br /> Describe Mpterial and Procedure <br /> I hereby agree to comp* y with all laws dnd regulations of. the;Wj:__ 7oaq_uin-�LoCEEI-Health District <br /> and the State of Calif o.r,ndra—pe-rta nttf o egulating 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 /> aWELL -DRILLERS REPORT of- the -well and notify them before putting. the well in use. The above <br />."information is true tothe• best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T R TING SPECTION. <br /> SIGNED TITLEji <br /> Zj%�� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f —72 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHAS I/FINAL INSPECTION <br />,-INSPECTION BY DATE INSSP�E,C`TION BY DATE —ZU--7� <br /> E H 142 6�. R '1- <br />