Laserfiche WebLink
_ L0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ForOF��ICE USE: 31601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> VY APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 3_s 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�� � �� f/ �'/'� C/ 1!Y7 ��;CENSUS TRACT C <br /> 6^ <br /> Owner's Name TI-� 1�� �1 [�'� QQC e' ��X11/d/Z Phone , �j9g Z77Z <br /> / %/ itiLS may► <br /> Address G ` City � <br /> r? 6�, 7g� 4verrn ° SSG_ <br /> Contractor's Name License �� Q 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <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 /> Domestic/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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done n <br /> PUMP .REPAIR: / ate Work Done ,�Zac Lqj/ wit _]�,�J/ C•u � L�'�.�p�� �� <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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A FINAL INSPECT U $aq Joaquin P1E631p Co. <br /> SIGNED TITLE <br /> ( PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Cafifarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY �. DATE - Z <br /> ADDITIONAL COMMENTS: 14 0 <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> n1 7 7 2M <br /> E H 1426 Rev. - 1-74 <br /> _ <br />