Laserfiche WebLink
SAN JOAQUIN LOtAL HEALTH DISTRICT_ x <br /> FOL TOFFICE USE: 1601 E. Hazelton :;Ave. , :Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> pe f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> IV 76 4 :7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .34Y-fie <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 Joaquii <br /> County Ordinance No. 862 and the Rules and Regulations of the San Joaquin Local H alth District. <br /> 57aCK7� <br /> .TOS ADDRESS/LOCATION D � � � /� � �70 f � �`�� �� CENSUS TRAC <br /> Y <br /> Owner's Name l Phone1� ' <br /> Address / s r AV /�Vl City <br /> Contractor's Name f_-1 .L_ roy R&-agS -1�,o 'A cense ' bla,, Phone 1lQZi03T,,0F <br /> TYPE OF WORK (Check): NEW WELL-jg DEEPEN /7 RECONDITION /_7 DESTRUCTION j <br /> f PUMP INSTALLATION / PUMP REPAIR'/7 PUMP REPLACEMENT /7 <br /> Other j/% <br /> DISTANCE TO NEAREST: SEPTIC TANK o+ ,/, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'"PIT OTHER,, y <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 1CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ofIWell Excavation- /p <br /> Domestic/private _Drilled Dia. of Well Casing <br /> 3 Domestic/public s Driven Gauge of Casing / <br /> Irrigation Gravel Pack- - Depth of Grout Seal 6610 c <br /> Cathodic Protection Rotary Type of Grout ' 7- <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed <br /> ,F PUMP INSTALLATION: . Contractor <br /> Type .of Pump .eases H.P. i% �. <br /> PUMP REPLACEMENT; / / State Work Done <br /> t <br /> PUMP .REPAIR: /7 :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebyagree to com l 'with all. laws and regulations of the San Joaquin Local Health District <br /> S p Y � q <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 FORA GROUT INSPECTION <br /> ' PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> E SIGNED E a, r�TITLE <br /> PLOlvftAN ON REVERSE SIDE <br /> FOR DEPARTMM USE ONLY <br /> PRASE IL2- — ,. . s <br /> APPLICATION' ACCEPTED BY ."A.Z2`2 v� 1. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE II F NAL INSPECTION <br /> INSPECTION BY L44DATE= C INSPECTION BY DATE _6 <br /> E S 1426 'Rev. -I-74 ? "2M <br />