Laserfiche WebLink
• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF }FFICE- USE: 1601 E. Hazelton Ave. , Stockton, Calif.. ��� ! <br /> 5 41, <br /> Telephone; (209) 466-6781 1�v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 AQ <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 Rulg§ and Regulations of the San Joaquin Local Health District. <br /> 17112-- gk <br /> JOB ADDRESS/LOCATION <br /> i CENSUS TRACT <br /> Owner's Name 2I a z= i Phone SKS- kZ,_ , <br /> Address (AC-L) City <br /> an Joaquin rump co. <br /> Contractor's Name (Division of San Jooquin Sufphur Coo License # Phone <br /> 711 Sacramento . <br /> I � <br /> TYPE OFWORK(Checl TT7—N ELZ/�/--DEEPEN/=/•- RECONDITION -/_-/,_DESTRUCT'ION_/_7 <br /> AL <br /> PUMP INSTLATION / UMP REPAIR / / PUMP REPLACEMENT /7 "Y` v-- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domesti-c/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information \(� <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,g, <br /> Te of Pump p �"�c-L/ t H.P. <br /> .L.....J,_, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 bell f. I WILL qM L,FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. rump Co, <br /> SIGNED TITLE (Division of San Joaquin Suightrr Co.) <br /> ( PLOT PLAN ON REVERSE SIDE) 7ii H, cramera a ul <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY r 1/ DATE a Z 2 <br /> ADDITIONAL COMMENTS: <br /> a ,- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DTE �� ((. T <br /> �� <br /> E;H 1426 Rev. 1-74 / /S'aJ`/Jo Q �� <br /> _= -- - _ Thi <br />