Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. %-5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,5-,,0-?9 <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 F.s►,,,Sl 5jpC 8C- j°,C N31 04D /(3/� ,g�f+�t�� /�O CENSUS TRACT <br /> Owner's Name Z no / ACL f 1 01 m C: Phone <br /> Address /2, 30 X zii��f'j'lO ,IE q lJ City Z4©/ <br /> Contractor's Name ii2ito aQ License #,7/03740"' Phone 'k5011?—V <br /> 0. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /-7 Gt- <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 tA <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 ,Sjg� �s V- <br /> Type of PumpH.P. <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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN FINAL INS CT ny J�, <br /> SIGNED TITLE SAiY JOAI��N P.J�4� C� ff.Vo�l <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY P. 0. Box 201 S <br /> PHASE I <br /> APPLICATION ACCEPTED BY� )�' <br /> a ✓c� Lodi, C is 05240 <br /> � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , �Z 9 <br /> _ 2M <br /> E H 1426 <br />