Laserfiche WebLink
FOR OFFIC USE: <br />l6)--7‘ 2-6 <br />Address (34. e o City 7_12 ,134451-40w)---- <br /> <br />Contractor's Name c'..c,A,1)024(17? License # 4%.1?2,2,1"--Phone <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7711061e <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 41201-„i <br />(Complete In Triplicate) <br />Applicatidn'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 Joaquin' <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />77.3 _"----='s"\-7- -F-c fr <br />JOB ADDRESS /LOCATION A, /d7 ,/1/47)1L,e4.1,4 (- ,-- 0 142 -747(Ae CENSUS TRACT '0 /_ 49260,- 03 <br />A ( A 4 Itt7 1.040Nr4/- {-#.c. 'A 4Di e CP.A. <br />Phone <br />TYPE OF WORK (Check): NEW WELL /1 DEEPEN f-T RECONDITION If DESTRUCTION /7 <br />PUMP INSTALLATION II PUMP REPAIR D(/ PUNT REPLACEMENT I7 <br />Other / <br />DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> <br />OTHER <br />Owner's Name /4 • C--Y-6 c_e _r <br />TLE <br /> <br />'INSPECTION BY <br />7/72 IM <br />INTENDED USE <br />Industrial <br />Domestic/private <br /> Domestic/public <br /> Irrigation <br />Other <br />TYPE OF WELL <br /> Cable Tool <br /> Drilled <br /> Driven <br /> Gravel Pack <br /> Rotary <br />Other <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />'Other Information <br /> <br />c4h) 0/-1' PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />„DESTRUCTION OF WELL: <br />Contractor <br />Type of Pump <br />127 State Work Done <br />/-7 State Work Done <br />Well Diameter <br />.--,„ <br />,so oe.A. <br />LIJJ °14/ f <br />H.P. / <br />an, flack/1i //1-P Fitt. <br />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. <br />SIGNED <br />W P PLAN ON 1ERSE SIDE) <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY -11--4y),,-2 <br />'ADDITIONAL COMMENTS: <br /> <br />DATE /6) - 7.2 <br /> <br />II GROUT INSPECTION • PHAS,A0 I FINAL INSPECTION <br />DATE /7 INSPECTION BYACIPIMI, <br />1/ <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426