Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F(,n'OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 2 -IldVl <br /> SIV&& THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,�E�d-,7) <br /> NI-14 (Complete In Triplicate) <br /> Application is hereby made to'! the San Joaquin Local Health District fora 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 Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c9 1 J �� CENSUS TRACT <br /> Owner's Name Phone` <br /> Address �5:L. City " <br /> Contractor's NameLicense #ccAydjo Phone 440A <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 41: Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION:c ' Contractor <br /> 4id <br /> f Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / StateWork Done <br /> PUMP -.REPAIR: / / State Work Done <br /> IDES•TRUCTION OF WELL: Well Diameter '" � ' Approximate Depth <br /> Describe Material and Procedure <br /> �' 'h6-fi by-akV66"to`'comply Vit'h-411 laxas and regulat'i6ns"of the' San Joaquin Local Hd il:th"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 iaell and notify them before putting the..well in use. The above <br /> information is true to the-best of. my knowledge and belief. I WILLCALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTINGS FINALS CT ION. <br /> SIGNED TITLE � <br /> ;l I (DRAW PLOT PLAN ON REVERSE SIDE} <br /> I FOR DEPARTMENT USE ONLY <br /> } PHASE- I i <br /> i. APPLICATION ACCEPTED BY DATE ���3'� <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHA E I /FINAL INSPECTION <br /> INSPECTION BY DATE N INSPECTION BY <br /> e <br /> .� , it 1 77 _{�2M <br /> R R 1L9A Rav_ 1-7A <br />