Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F0 . OFFICE USE: ' 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27 fG(/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued':26-7 7 <br /> (Complete In Triplicate) <br /> Application hN iereby 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 CENSUS TRACT <br /> Owner's Name 4EI 6a,14- vzeyluPhone 03 2 G S/S' <br /> Address <br /> City _Jo�Vc a 4.v <br /> t <br /> 4 Cdntractor's Name t - License �� / C phone gyj�SA1S <br /> ��TVPr,nI?WORK -(Check) :_.NEW- WELL / m., DEEPEN. /-/-,.--RECONDITION .?-7 DESTRUCTION /7 -:- <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKV ..— _ SEWER LINES PIT PRIVY loo �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEVAGE PIT OTHER <br /> PROPERTY LINAP PRIVATE DOMESTIC WELL _20-+ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> { Industrial " Cable Tool.. Dia. of Well Excavation _J2 " r <br /> kDomestic/private Drilled Dia. of Well Casing ► <br /> Domestic/public Driven �, Gauge of' Casingu, <br /> ` Irrigation Gravel Pack .Depth of" Grout Seal <br /> f <br /> i Cathodic Protection Rotary Type• of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: f (� <br /> PU1P INSTALLATION: -Contractor <br /> Type of-Putip.:_ . <br /> H.P, <br /> P2-T REPLACEMENT: . / / State Work Done <br /> �..�t... -tea. <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: - Well Diame-fery <br /> 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 /> J after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of the well an notify them before putting the .well in use. The above <br /> information is true to t b t y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G INGAND A <br /> SIGNETTITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPA1 TMENT USE ONLY <br /> PHASE I Of(I PJr <br /> APPLICATION ACCEPTED BY �� . � <br /> DATE J -7� <br /> ADDITIONAL COMMENTS• "'�-' <br /> I PHASEtf-G NSPECT O P E SINAL INSPECTION <br /> INSPECTION BY DATE j INSPECTION BY TE f" 7 <br /> I .. E H'1426 upt. _7 , 1177. <br />