Laserfiche WebLink
r <br /> .., � jW SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: �e6bl E. ;Hazelton Ave. , Stockton, Calif. <br /> . telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77- 5e,?04J <br /> 77-76/ ld <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health'I.District. <br /> I <br /> JOB ADDRESS/LOCATION I7Z�3 $'� /*/ Al ,/� z3'r-%5&/�ENSUS TRACT Ii, <br /> Owner's Name 4r,/ % <br /> /S'� Phone""$,-74g�I e <br /> Address`e>a4o"'�S- .5'- AV-S 14//WAKF~ City �Z <br /> Contractor's Name /Y' License # Phone i <br /> .Ij <br /> TYPE OF WORK (Check) :-"NEW`WELL -/ / DEEPEN /_/ RECONDITION /_/ DESTRiJCTIbN' /� Al. <br /> PUMP INSTALLATION `/ /.'• PUMP REPAIR / / REPLACEMENT /7 <br /> Other.L1 <br /> / Ae <br /> !�. _j <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 O SEWER LINES JOS— PIT PRIVY <br /> SEWAGE DISPOSAL FIELDZifQ" CESSPOOL/SEEPAGE PITS/✓e-OTHER JYd�Y <br /> PROPERTY LINE .- PRIVATE DOMESTIC WELD` PUBLIC DOMESTIC WELL !"VIA✓ UJ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! <br /> Industrial Cable Tool ,, ., Dia. of Well Excavation /yam' <br /> Domestic/private Drilled Dia. of Well Casing / ij <br /> Domestic/public Driven Gauge,,of Casing r' Skye,> Ij <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: L <br /> I PUMP INSTALLATION: Contractor ®•Gc�/vL�7� <br /> Type of Pump - `T_1P/ 'A Al - -- - H.P. 49 <br /> PUMP REPLACEMENT: / / State Work Done T <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 7� 3.j--o` <br /> ilr <br /> Describe Materials and Procedure <br /> % Ir <br /> ..I hereby agree to comply with all laws ,and regulations of the San Joaquin Local Health District <br /> lanu 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 bistrict 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 6U-my -knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> 'PRIOR TO_-eRn`U_TjNG MD A AL I SPXCTION. <br /> SICNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br />' .! <br /> PHASE I <br /> n � ip <br /> APPLICATION ACCEPTED BY ��, 1L" DATE <br /> ADDITIONAL COMMENTS: ii <br /> PHASE 11 ; ROUT INSPECTION PHA$E7 TT I/ .INAL INSPECTION <br /> _INSPECTION BY - ) DATE INSPECTION BY/ // �' - DATE , <br /> E H 1426 L Rev-1-74 <br /> 1�'77� 2M <br />