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.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S 7� <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 lthe Rules and Regulations of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION 92 1RLCENSUS TRACT <br /> Ow Ib� <br />{ _Nn�Owner's Name Phone <br /> Address . lox vt City 45Tq0k) <br /> Contractor's Name � ���, A i it IA41 I t W License # 02- Phone A2,is7/ <br /> { i <br /> t <br />, TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION_/ / DESTRUCTION /_7 It <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP- REPLACEMENT /_T <br />( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL, <br /> INT ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable:--Tool Dia. of Well Excavation /Z'� 1 <br /> Domestic/private . Dri*1,1e_ d Dia. of Well Casing IR t t <br /> Domestic/public Drivejl \ Gauge of Casing = s <br /> Irrigation vel Pack Depth of Grout Seal <br /> 4 Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information L <br /> Geophysical Surface Seal Installed By: ! <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump , H4.P., 1: , <br /> PUMP REPLACEMENT: / / State Work Done 4 JA K_ - <br /> PUMP .REPAIR: / / State Work Done f" €� <br /> DESTRUCTION OF WELL: Well Diameter 1 +�Approxii� to Depth <br /> k' 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..welltin use.. Thel above <br /> _information is e t the best of my knowledge and belief. I WILL CALL! FOR A GROUT INSPECTION <br /> PRIOR TO G 0 A FINAL INSPECTION. <br /> SIGNED TITLE L6 0 <br /> _•..:.:.:.._ .. _.�, - _� . �_.. (DRAW_P.LOT_PLAN,ON-REV.ERSE_SIDE), <br /> FOR DEPARTMENT USE ONLY x <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE5-V? 'Z <br /> ADDITIONAL COMMENTS: 3 <br /> PHAS4 II GROUT INSPECTWN PHASE III/FINAL INSPECTION <br /> INSPECTION• BY2- r DATE INSPECTION BY DATE 1 } Z) <br /> } 2H <br /> � E H 1426 RA�r_ 1-74 _ , - 1177 - - - <br />