Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FflR pyFICE USE; 1601 E. Hazelton Ave- , Stockton, Calif. <br /> Telephone-. --(269) x+66-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l ..YEAR FROM DATE. ISSUED Date Issued <br /> (Complete ,-In Triplicate) _ - <br /> Application is heieby 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 Regulations of the San Joaquin Local Health District. <br /> K00�_AngA,) BQoS, OA 144- <br /> JOB <br /> 44-JOB ADDRESS/LOCATION arde&A.cs L,, weli S n- "OF CENSUS TRACT <br /> Owner's Name l�lN kgpY�rl�4� Phone <br /> Address• <br /> ` Tfro, %aa �d a city �a® / <br /> k '- �3 2�3 ivy"i; <br /> Contractor's Name 3_2 V"tx] A407re License # Phone <br /> :TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION DESTRUCTIONS/7 <br /> PUMPIINSTALLATION / ] PUMP REPAIR'M PUMP REPLACEMENT X <br /> Other L-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY V� <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By-. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ] State Work Done r ." b,4 " r '1 <br /> PUMP :REPAIR: /7 State_Work Done_ - <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin' Local Health Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> information is true to thelbest of my knowledge and belief. I WILL CALL FoR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> + �� <br /> TITLE (division of San Jeoquin Sulfur Co.) <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CONNENTS: i <br /> PHASE II GROUT INSPECTION PHASE ffEFINAL INSPECTION <br /> INSPECTION BY t DATE ' INSPECTION BY DATE 776-7e- <br /> `i E H 1426 Rev. ].-74 4 2MG <br />