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. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED mate Issued 1-d ? 715'p <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 /3 'O$— $ ,40.!'7-/N /QD, CENSUS TRACT <br /> Owner's Name 1_6-Ck 1t,4 I Z ESQ Phone yw y Z.7 Tf <br /> Address Z 36 A1, 14 F_ � 37". STo KTO J City S7'OGKTOAf <br /> Contractor's Name /j/pegLK ,yjQ fN�, License #2007 Phone t7W-$'r/7 <br /> TYPE OF WORK (Check) : NEW WELL /_ DEEPEN / / RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 (A <br /> Other / / o <br /> DISTANCE TO NEAREST: SEPTIC TANK gD, SEWER LINES ! PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <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 4_0-V <br /> _ 7X Domestic/private Drilled Dia. of Well Casing 61" <br /> Domestic/public Driven Gauge of Casing fZ GA. <br /> Irrigation t� Gravel Pack Depth of Grout Seal <br /> ^ <br /> Cathodic Protection Rotary Type of Grout T 1yO�t1M./T-,E <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: . wo,4eK <br /> PUMP INSTALLATION: Contractor Zy0!1C_f< /0Um/J //VG, <br /> Type of Pump .7tJBm 02 51/164 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> PES•TRUCTION 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 DAIS <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 GROUTIM AND A FI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY �j/�Y/�8 <br /> APPLICATION ACCEPTED BY -z_ DATE \-,-LI 8 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE• II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE' <br /> E H " " G" r L�,l`i8 c9?0'r �2M <br /> 1426 Rev. 1- �'" - <br /> 74 <br />