Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
f - <br /> � 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 <br /> (Complete in Triplicate) / 2-7--g-00-6 2- <br /> Application is hereby made tosthe 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 /> JOB ADDRESS/LOCATION ` N! 0 OF i 4-nox A H1 E of LAENSUS TRACT <br /> Owner's Name d u 1 T L I e�. �-� T� � Phone <br /> Address �t= �.�� r LC . _ City <br /> Contractor's' Name liL k�, L�Ei� e MAI P�F.IV L 0�- - License # &d Phone <br /> E —� <br /> { <br /> TYPE OF WORK_ (Check): NEW WELT, / ' DEEPEN / ''RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION: / 1 PUMP REPAIR -7 REPLACEMENT <br /> /, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD., CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY'-LINE-- PRIVATE I DOMESTIC-WELL== -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 12 <br /> Domestic/private Drilled Dia. of Well Casing <br /> vp Domestic/public Driven Gauge of Casing 1` <br /> r Irrigation Gravel Pack Depth of Grout Seal- <br /> Cathodic <br /> ealCathodic Protection Rotary Type-, of Grout <br /> ' Disposal Other Otherzlnf6rmation "4 . <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor CL (i(� LL C�}Gtln E1.4- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP"-REPAIR: . /? State Work Done <br /> S . <br /> t _ <br /> RES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and_ .regula:tionsaof 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 /> 1 <br /> informatioA is true to the"bestf my knowledge and belief. I WILL CALL FOR"A "GROUT INSPECTION <br /> PRIOR TO GltoTJTING AND IN PECTI . <br /> SIGNED TITLE <br /> E LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BDATE /`/ ZY <br /> ADDITIONAL COMMENTS: <br /> PHASE TI GROUT INSPECTION P II/ AL INSPECTI N <br />" INSPECTION BY DATE INSPECTION DATE <br />� � E H 1426 Rev. 1-74 1-74 2M . <br />