Laserfiche WebLink
SAP' TOAQUIN LOCAL. HEALTH DISTRICT <br /> OH OFFICE USE: 1601 h.iHazelton Ave. , Stockton, Calii-a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2;?- 04'4&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Sy_77-77 <br /> (Complete In Triplicate) <br /> ?lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i/or install the work herein described. This application is made in compliance with San Joaquin <br /> unty Ordinance No. 18t2',and <br /> � e£u�es an�Le�gulations of the San Joaquin Local Health District. <br /> B ADDRESS/LOCATION LJ UJ ' ,5v ✓� NSUS TRACT <br /> Zer's Name/�e/ Phone 7J ' <br /> cress 22 S cl y F A,4 1y Z,2 City C.alcni <br /> atractor's Name �i4N6iIi� L/)s/z /Lie[G License I12.7 %/r/ Phone �yJ-g192 <br /> ` a <br /> ?E OF WORK (Check) : NEW WELL /r DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /7 <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 12 (A` <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing /0�,p <br /> 1/ Irrigation Gravel Pack Depth of Grout Seal J <br /> _ Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> _Geophysical Surface Seal Installed By: ,�,. E1-oN <br /> T INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> T REPLACEMENT: / / State Work Done <br /> T .REPAIR: / / State Work Done 0 <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> cer completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :.L DRILLERS REPORT of the well and ijotify them before putting the well in use. The above <br /> ormation is true to the be oVmknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .OR T D NG D A F I NSN <br /> ,NED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1SE I <br /> ?LICATION ACCEPTED BY jkvDATE <br /> )ITIONAL COMMENTS: 4z z <br /> P I GROUT IN ECTION PHAS I !/ NAL ,IN PECTION <br /> SPECTION BY DATE INSPECTION BY : DATE <br /> 2M <br /> 1/77 - <br />