Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Permit No. 79,29 <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3-� <br /> (Complete, ln 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 /> f;3010' k) 14 t amu/ 132 (�}� 94A1 All') _ z-Ss-- 0-7 o-r 2-. . <br /> � <br /> JOB ADDRESS/LOCATION <br /> 1 r4(!p FsSS � M FAST OF s/P1] geD i2 #NSUS TRACT <br /> . Owner's NameSLLV Phone <br /> Address <br /> 1,f AM City ? ul <br /> k Contractor's Name <br /> LLf License # 122S2 'Phone E3`-7�3 <br /> ' TYPE�,O&.�WORK-(Ch(jck)`; NEW LL /. DEEPEN RECONDITION /7 DESTRUCTION /-7 <br /> PUMP 11Q$TALLATJON,./ P" PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other 's <br /> DISTANCE TO NEAREST: SEPTIC- TANK �x' SEWER LINES PIT PRIVY <br /> A10 -SP-P7-1 C '7-AN11C-SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> (y@ I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS $ <br /> Industrial� Cable Tool Dia, of Well Excavation " c <br /> Domestic/private Drilled Dia, of Well Casing " <br /> 41 <br /> Domestic/public i Driven Gauge of Casing PVC 1/'o - <br /> Irrigation T_>e Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection � '�, Rotary Type of Grout - <br /> Disposal Other Other Information yN <br /> Geophysical <br /> FOCI; GULL. Surface Seal Installed By: <br /> i <br /> E PUMP INSTALLATION: Contractor <br /> ~` Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP .REPAIR: / / State Work Done` t <br /> DESTRUCTION OF WELL: Well Diameter "' `' ' <br /> . 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 Californ`i'a 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 /> IPRIOR TO GROVIq6 AND A FINAL INSPECTION. <br /> SIGNED _ .� TITLE' <br /> (DRAW. PLOt PLAN ON REVERSE SIDE) <br /> 1 } ` FOR, 'bEPARTMENT USE ONLY <br /> PHASE I , . <br /> APPLICATION ACCEPTED BY r` _ <br /> UJ DATE - <br /> iADDITIONAL COMMENTS: <br /> PHASE II GROUT,,INSP;ECTION " PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE'; ,�; ►h : ��' a INSPECTIY ATE /J <br /> E H 1426 Rev. 1-74 ; 1777 - aM <br />