Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -TOT-"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calf.- - 77_y=71V <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �27-/3,� G.) <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . . o <br /> N TRACT <br /> t� pp <br /> Owner's Name �, L; j0eweLel Phone <br /> Address (°6A V1(UA City <br /> Contractor's '104dll*Ilov , License # o2i?,o /' Phone L52.2-AQ3/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ° SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -L--iL- CESSPOOL/SEEPAGE PIT OTHER u)P!/-,30 ' <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 r <br /> Domestic/private Drilled Dia. of Well Casing �► <br /> Domestic/public---- Driver3-- - -- Gauge--o€ Casing _ - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Alt2 <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 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -P / oximate Depth <br /> M' tribe rial an Pr cedure <br /> I hereb�- comply with all laws and reg-uliofinns of the San J aquin 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 /> ALL 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 <br /> FOORA GROUT INSPECTION <br /> PRIOR <br /> SIGNED 0 G OUTING AND FINAL IASPE.CIION. TITLE <br /> W PLOTPLAN ON RE SE SIDE) <br /> DEPARTMENT ,USE. ONLY <br /> PHASE I L /, <br /> APPLICATION ACCEPTED BY % DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT IDJSPECTIOPHASE III/FjNAL INSPECTION <br /> INSPECTION BI � ATE 7 INSPECTION BY DATE <br /> 47L <br /> E H 1426 �fev.lc 1-74 3/76 2M <br />