Laserfiche WebLink
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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �y <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 Jo4quix <br /> County Ordinance No. 1862 and the Ru% s and Regulations of the San Joaquin Local Health District. <br /> V'oZg41 ..E. �•w,)= A-0 - y��o �. d, r - .z.2 � )' �, ' ,� 19-7--0e0-e3 <br /> JOB ADDRESS/LOCATION _ c . _ CENSUS TRACT <br /> i n/ <br /> Owner's Name _—., /} _C. �� .gI�IJ y S:O S -Al Phone <br /> L f <br /> Address 7COO = City S%4G�r'Ta Al _ <br /> Contractor's Name :C License # _•Phone ,"2 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION_/�',�DESTRUCTION /_7 <br /> I PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,r� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation ?j-. <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven- Gauge of Casing <br /> 4 Irrigation-l- Gravel- Pack Depth of Grout ,Seal <br /> Cathodic► Pr_otectiori�'..'• Rotary Type of Grout Disposal Other Other Information <br /> i <br /> Geophysical Surface Seal Installed By: g - <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> ! PUM-P?REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> ;DES•TRUCTION OF WELL: Well Diameter Approximate Depth $:' w <br /> ' Describe Material and Procedure <br /> iI hereby agree to comply with all law's-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 <br /> WELL DRILLERS REPORT of the well and notify them b-e-fore 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 GROUTING AND A FINAL INSPECTION.' <br /> J SIGNED 0 4/ Z 4=7 so A' , _Lw C, TITLE 10 JA 51? <br /> ` (DRAW PLOT PLAN ON. REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> CHASE I <br /> ( <br /> PLICATION..ACCEP.TED-BY�._ <br /> ADDITIONAL COMMENTS: <br /> PHASE II' GROUT INSPECTION" PHASE 'III/FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY /� DATE 7-40 `7-P <br /> s y <br /> U77 <br /> E H 1426 RPsr_ 1-7L <br />