Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT NA L --ro 644wN� � <br /> F' hM1OFxCE USE: I` 1601 E. Hazelton Ave. , Stockton, Calif. OC, <br /> ,4 Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 <br /> THIS PERMIT EXPIRES l 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'jherein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. .186ii2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONSrD �j Z - �j�ef e4- CENSUS TRACT ' <br /> Owner's Name —. B Ut2 Phone _�3g,ZyoZ- <br /> Address Z�83 2 ���. P iA�1Z I P, LAS r��.. — City.. 'G j , <br /> Contractor's Name` License,# PhoneAaov I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEP. N / / RECONDITION_/ / DESTRUCTION /-7 _ <br /> PUMP INSTALLATION PUMP *REPAIR / / PUMP REPLACEMENT <br /> Other :C-� T <br /> DISTANCE TO NEAREST: SEPTIC TANK . _ SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC W.EL L . 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. Weil 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 Installed By: <br /> PUMP INSTALLATION: Contractor AQG✓/✓F-!lam <br /> Type of Pump. H,P. <br /> PUMP REPLACEMENT: 5t�te Work Do e __ i <br /> Coe <br /> PUMP .REPAIR: /G. / State ork Done �� "C/4�(f� i <br /> !.. pit f -ro R r-0 OF U S'L <br /> DESTRUCTION OF WEL : We 1 Diame r Approximate Depth <br /> D`6scribe 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 'consrruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of ]lthe well and notify them before putting. the. well in use. The above <br /> informat' n is true to the best of- my knowl'e'dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR VROUTING AK6_7':" <br /> F;,;NAL_1NSPFwCTION. <br /> SIGN -- J TITLE <br /> !p. kWW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y <br /> ADDITIONAL COMMENTS: II. <br /> PHASE II GROUT INSPECTION PHASE V,?1FTNA1,o INSPECTI N <br /> INSPECTION BY IMT DATE INSPECTION BY DATE <br /> 4 E H 1426 Rev. , 1-7j <br />