Laserfiche WebLink
P 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. 2 <br /> 75 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /Z_7•�, <br /> ' N. (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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Zq 17S LL FGA CENSUS TRACT <br /> u • <br /> Owner's Name POR_7_QA1 „ „ --- Phone <br /> Address <br /> City 1n�d/-r <br /> Contractor's Name G 1-r License #2,pp q Phone / 7 <br /> TYPE OF WORK (Check) : NEW WELL /,V DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 4 <br /> ' PUMP INSTALLATION ;'UMP REPAIR / / FUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST:_ SEPTIC TANK �, SEWER LINES loo <br /> 't PIT PRIVY 4 <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- � = <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS b' <br /> Industrial �� Cable Tool Dia. of Well Excavation /p h, <br /> Domestic/private N Drilled Dia. of Well Casing <br /> Domestic/public ?, Driven Gauge of Casing �6A. <br /> Irrigation " - Gravel.-Pack ' .Y + Depth of Grout Seal Sp i s <br /> Cathodic Protection__ Rotary '',`.q` Type of Grout _gq,9d,�ZVLVZ7E <br /> Disposal. Other `-� Other Information <br /> Geophysical --, i' "Surface Seal Installed By: /l/4ACK <br /> PUMP INSTALLATION: Contractor—._.--, �' C <br /> T-`Ype of Pump — .� �es�L,E H.P. y1Z <br /> PUMP REPLACEMENT: <br /> L / / State Work Done <br /> PUMP 'REPAIR: t <br /> 1 <br /> /li./ State Work Done.,�r.� <br /> _. W.. <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth .- <br /> Describe..Material ,and_Procedure <br /> I hereby agree-t-o' complyl;with all laws and regulations-bf-the Sar' Joaquin Local Health District <br /> and the State of California 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 /> PRIOR TO GROU NG AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I� ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: GZe <br /> P II G UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /2 - ^7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1777. , . 2M - <br />