Laserfiche WebLink
43414,0/,t4,w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> Ca lot"mm*- `�'` f s4" � 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 `Od )y x IGa 6z CENSUS TRACT <br /> Owner's Name S�jZ&A -r 4- Phone <br /> Address <br /> City JV41� <br /> Contractor's Name } License # <br /> g8,7 j 'Phone c. {,y --7-C,76 <br /> i <br />' TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_kf PUMP REPLACEMENT /- <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 Q <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 <br /> --Installed By: <br /> PUMP INSTALLATION: Contractor �­4,.) ./ r. <br /> Type of Pump !777-1e_.,-,beJrt H.P. <br /> PUMP REPLACEMENT: /7-/ State Work Done <br /> PUMP .REPAIR: / State Work Done d " Z6 l <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 thewell in use.. The above <br /> information is true to the best o£ knowle,4ge--- d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPUTI <br /> SIGNED TITLE L <br /> -(Mw rLUT PLAN ON EVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��T 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHk;SEhjI44FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY N 1%43r, DATE \t)-k61-11 <br /> E H 14.26 Rev. 1-74 <br /> t IR 2MQ3 <br />