Laserfiche WebLink
! SAN JOAQUIN LOCALLTH DISTRICT <br /> v< <br />' ' FOE OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone:T (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,,- 5 6, <br /> � 76_24S'f' <br />'E THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued L J7-J� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r L Al CENSUS TRACT <br /> Owner's Name OOL I!U Phone L� (o Z l a <br /> i Address d 6 f _ A L-/V City O /J 1 C t9 L1,4C- <br /> Contractor's Name �/!rd Cgo r,,� Z PRt41-Z&'K I License lianw-k Phone7 <br /> TYPE OF WORK {Check) : NEW WELL DEEPEN / / RECONDITION /�/, DESTRUCTION <br /> _. <br /> PUMP�NSTALZATION"/�"/4Y'PUMP'REPAIR"/_/�' PUMP REPLACEMENT <br /> Other: <br /> DISTANCE TO NEAREST: SEPTIC TANK /a S` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP.00L/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'' PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL. - CONSTRUCTION SPECIFICATIONS p <br /> Industrial X Cable Tool Dia. of Well Excavation 17-!v \ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of"Casing <br /> d, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> .x. b F a. <br /> Cathodic Protection:;'::"' ,.Rotary Type of Grout <br /> Disposal Other Other Information:-a , <br /> Geophysical Surface .Seal Installed By: <br /> PUI�INSTALLATION: Contractor <br /> Typejof Pump H.P. <br /> PUMP REPLACEMENT: . !-State Work Bone r. <br /> 1 _ <br /> PUMP .REPAIR: / / State"Work Done - <br /> DES-TRUCTION OF WELL: k 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE S✓ <br /> DRA L- PLAN 'ON REVERSE SIDE <br /> 10R .DEPARTMENT USE ONLY <br /> PHASE I � 17APPLICATION ACCEPTEDDATE -7a <br /> { ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY ! DATE INSPECTION BY C . DATE <br /> E H 142b Rev. 1--74 ; <br />