Laserfiche WebLink
Er11v S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.- <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6--6- 7 c/ <br /> F (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 Joaquit <br /> County Ordinance No. 186� and the Rules and Regulations of the San Joaquin Local Health District. <br /> T J. 4A�1-tG o ,p �P,� : !a(-Z2&-- ©V <br /> JOB ADDRESS/LOCATION ����-� ��6 � / CENSUS TRACT <br /> Owner's. Name - 2J Phone _ <br /> k Address _ (� C7-.Z a 3 - C'J� L, / V Cl y" � City 's� .2-6 <br /> Contractor's Name � Z7 Pt 'L_14/ License A 6a-373Phonea46�— <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other 5/ J AJ S ,1_L_ D/N <br /> Lb EL L_ , <br /> DISTANCE TO NEAREST: SEPTIC TANK r . SEWER LINES PIT PRIVY'_....,,..,_..,..„. <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Z <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4 Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> .. Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed BY: - <br /> PUMP INSTALLATION: Contractor Z <br /> Type of Pump H.P. Q <br /> PUMP REPLACENENT: / / State Work Done <br /> _ =__ -.�.e�.6 ;' :- — _w�J�'t--�-•v-. Jam+-.'.�w�Fe.�-- <br /> PUNP�REPAIR: State Work Done eo <br /> 7r® N . <br /> J?E5'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 'III I hereby agree to comply with alllaws 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 AND A FINAL INSPECTION. <br /> SIGNED _ ,ram n.A__r- TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S-;--30, - <br /> ADDITIONAL <br /> 5-;--3f, "ADDITIONAL COMMENTS: <br /> I PRASE II GROUT INSPECTION ; PIJA FIN NSPECTION <br /> INSPECTION BY DATE INSPECTION ATE <br /> i <br /> 1S E H 1426 Rev. 1-74 + 1-74 2�r <br />