Laserfiche WebLink
0V2 K, JOAQUIN LOCAL HEALTH DISTRI`,./ <br /> FOF OFFICE USE L' <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqu <br /> County Ordinance No. 18`612 and/the Rules and Regulations of the San Joaquin Local Health District <br /> Y JOB ADDRESS/LOCATION <br /> Z _5 , Y6I CENSUS TRACT <br /> Owner's Name boi ( -44 I O Phone 9( S <br /> 7 <br /> Address Zy i bi• City ..<Lcicly <br /> Contractor's Name License ! Phone <br /> V6 YBO <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_ \ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 p/ Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorQ, (:�4zv I fga-r Co - <br /> Type of Pump _�� H•P• 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> :LL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> '.OR TO GR94YING QND/A FINAL INSPECTION. <br /> :NED -:&AL -Z,PAf27-7�_-_ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> LSE I <br /> 'LICATION ACCEPTED BY �, y , !i1` DATE j2-,).-f -77 <br /> )ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> PECTION BY DATE INSPECTION BY DATE ; <br />