Laserfiche WebLink
LL Ch o ONN JOAQUIN LOCAL HEALTH DISTRIC^ <br /> FOF OFF CF USE: 16(v.oE. Hazelton Ave. , Stockton, Car..;. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �G <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 Joaqui <br /> County Ordinance No. 18' , - <br /> 62 and/ 3L the Rulesand Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L z , , `� �� CENSUS TRACT <br /> Owner's Name bo_t - 6�'f'Y to (Z '. 1 q �t Phone -& S 7 <br /> Address `i 2- > 6 S . � � j W• l 1 City iV <br /> Contractor's Name Dy M ,eA, Pi, ., . co' . License # 173y'Z Phone </62 ti�a3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> ALL <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! �J Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor\ 1 n1( .�C,�.2 �J,.np Co - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> 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. Within FIFTEEN DAYS <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 GR�I�ING �ND�A FINAL INSPECTION. <br /> SIGNED _ /C�// // (J/�r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> 1PPLICATION ACCEPTED BY ma y. if DATE /1 -,�79 77 <br /> ')DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ,PECTION BY DATE INSPECTION BY DATE <br /> 0/77 9m <br />