Laserfiche WebLink
SAN JOAQUIN�LOCAL' IEALTH*DISTRICT <br /> Farr <br /> 0F,rICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,,77 r <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUSD Date Issued 6-�7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fox 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 Sass Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . �J J gaAlYllj�ve, h m I f CENSUS TRACT <br /> Owner's Name L/ G Phone ' <br /> Cit �l3S� Lz <br /> Address /3 f - A✓ a y �:.•��i <br /> Contractor's Name ! IAC, License �.Z�O /3 Phone��/ <br /> TYPE OF WORK (Check): NEW WELL 1;;r DEEPEN -/- RECONDITION /_7 DESTRUCTION �'„ <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> Other / o E <br /> / -�- <br /> f, }, 1 <br /> DISTANCE-TO_N : SBFITIC: ANK�� o SEWER LINES-%30-, PIT PRIVY <br /> SEWAG�"EISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY DINE - PRIVATE DOMESTIC.WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `. CONSTRUCTION SPECIFICATIONS <br /> # Industrial . Cable Tool •'D`i.l�,. of Well Excavation _ " '/•2'� <br /> Dome tic°/ *rivate Drilled I.Mia. of Well Casing , <br /> Domestic7ublic Driven '`"O°auge of Casing Sec• �o <br /> Irrigationy Gravel Pack Depth of Grout Seal <br /> Cathodic*,�Totection `'xk Rotary Type o£ Gro x G, <br /> Disposal C''• • ;i. 1 <br /> Other # Other Information <br /> Geophysica4L ° ;, Surface Seal Insta led B` <br /> PUMP INSTALLATION: Contraetor �'` <br /> p Type+o f::-Pump <br /> PUMP REPLACEMENT: / / State Work Done; '• T . •€ r ` <br /> PUMP ,REPAIR: / / State Work Dome_: ., INA .- <br /> DESTRUCTION OF WELL: WellaDiai�ter Ds�x• ' 'Approximate Depth <br /> Describe*MateriaI- an Procedure <br /> t I hereby agree to complyrwith all laws and regulations-cf.-•the .tf._Joaquin Local Health District <br /> And the State of Califbrni petnig-t'o-; rregul"ating well:'consCruction. Within FIFTEEN DAYS <br /> after completion of my' work on a new well,:; Vwi l famish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT df lthe well---Ano notify them;before putting the..wellin.use.... .The above <br /> information is true to the-best-of- my ,knoftedge, and belief. I WILL CALL. FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND 'A'VINAL INSPECTION. = 1 ' <br /> SIGNED G 1� r" TITLE <br /> (DRAW ZLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 6 <br /> PHASE I ,�Y ` k <br /> APPLICATION ACCEPTED BY 4 DATE ' <br /> ADDITIONAL COMMENTS: <br /> ,�, PHASE III .INAL INSPECTION <br /> -PHASE-II-GROUT INSPECTION'S '" ' _ T.._ <br /> INSPECTION BY, DATE 7;,j_= INSPECTION BY DATE <br /> x/75_- 2M � <br /> x. <br /> V. 9 147 _�pe�* 11-7/A � � - <br />