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. 7A-77 fzo r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 19 r /'A a? n- A CENSUS TRACT <br /> Owner's Name /" L6241- Phone ( "1.2- J� <br /> Address 1"df1mr7n. City 57 Q4 aA <br /> Contractor's Name 1'T'& ��'Qh _ ' License WZDL�s"Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN 'J� RECONDITION/? DESTRUCTION f7 <br /> "'PUMP INSTALLATION ZKf PUMP REPAIR /� PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC. TANK v SEWER LINES PIT PRIVY <br /> SEWAGE DISP6SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `}-• . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> !/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Dives Gauge of Casing AL <br /> Irrigation, Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection Rotary - Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 7/ �r <br /> F <br /> PUMP INSTALLATION Contractor <br /> Type .of Pump / _ r H.P. <br /> REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 GROUTIN A VIN SPECTION. <br /> SIGNED TITLE Y <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _� �,.,, - DATE '/D 9 "7 e <br />, ADDITIONAL COMMENTS: <br /> P E-II G UT-INSPECTIO)? 'PHASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY �- DATE-/ <br /> ;77;/ <br />