Laserfiche WebLink
SAN JOAQUI�f r,ACALIEALTH DISTRICT <br /> EOk-0FFICE+USE: 1� 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> `. Telephone; (209)' 466 -6781 <br /> a� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ,J THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7rGO q <br /> (Complete In Triplicate) i <br /> Application is Aereby madeto 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 /> E <br /> ` a <br /> JOB ADDRESS/LOCATION T r CENSUS TRACT ;11 <br /> • V M <br /> Owner's Name � Dfll'l , eM Ran U LL// Phone <br /> Address' City <br /> -2-6144L V, R1 yerRL <br /> Contractor's Name J�gnnj'yw ame2ry License Q Phone + i ) <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN_/7 RECONDITION /_7 DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /7 i ! <br /> DISTANCE TO NEAREST; SEPTIC TANK - SEWER LINES �� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL LCL PUBLIC DOMESTIC WELlo <br /> INTENDED USE TYPE OF WELL _CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ '• <br /> VDomestic/private Drilled Dia, of Well Casing 7 t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 157> <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ._.. K.P. I <br /> PUMP REP.IACEMENT-:, / / State Work Done ' `• - } <br /> PUMP REPAYR; /? State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> ��j••^ Describe MateriAl and Procedure ! <br /> I ere. y agree to comply with all laand regulations of the n Joaquin Lo al Health District <br /> and the"-.State of California pertaining/to or regulating well construction. Within FIFTEEN DAYS <br /> after com�p4etion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP©RT_af the.well and/notify -them before putting the well in use. The above <br /> information is true to he best_-of my knowledge and belief.' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. � { <br /> SIGNED TITLE ' ' f <br /> -_0#(DRW PLOT PLAN W I ERSE SIDE i { <br /> FOR DEPARTMENT USE ONLY ti 1 <br /> PHASE I E <br /> APPLICATION ACCEPTED BYAar= - - ` DATE 't <br /> ADDITIONAL COMMENTS: <br /> PHOE I GROUT INSPECTION Ppj�W ILIIIFAN&ILII/FANIN PECTION— - + <br /> INSPECTION BY DATE 7 INSPECTION BY DATE <br /> Rev. 1-7G 175��1�0 r.so�; �W1117 . 2M <br /> I H 1426 ' <br />