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. ,7g-]*S'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued za_—Iz� <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. 186,pd the Rules and. Regulations f the San Joaquin Lo a ealth District. <br /> d <br /> JOB ADDRESS/LOCATIOk3� ' CEN TRAC <br /> Owner's Name Q Phone -o-C-1Q� <br /> Address Q C�tYE m e ±o -C <br /> V j r <br /> Contractor's Name /'f License # hon <br /> TYPE OF WORK (Check) : NEW WELL/ 'Vr-DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/74-::PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES p.p PIT PRIVY, <br /> DOd/ ..__. <br /> SEWAGE DISPOSAL FIELCESSPOOL/SEEPAGE rIT OTHER --y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL --� <br /> l INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br />` Industrial Cable Tool Dia. ,of Well Excavation <br /> mestic/private Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of, Casing ./�- _ <br /> Irrigation Gravel Pack Depth of' Grout .Seal <7-0 <br /> Cathodic Protection 4---Rotary Type of Grout �U���f'� ---- Ga/1�C• Cv,� <br /> Disposal Other Other Information420 SL -1116 <br /> o 1 <br /> Geophysical Surface Seal' `Ins talled'B .: _ 'hr c. <br /> PUMP-INSTALLATION: Contractor <br /> Type of Pump <br /> j PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION ,OF WELL: Well Diameter Approximate Depth <br /> f 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: <br />