Laserfiche WebLink
SAN JOAQUIN LOCAL _HEALTH DISTRICT <br /> _FW*OFFICE USE: 3601 E. HazeltonJ,,rge. , Stockton, Calif. <br /> * Cr o 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 V �3-7�- <br /> (Complete In. Triplicate) <br /> # <br /> Application is hereby made totthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is mode in- compliance with San Joaquin, <br /> County Ordinance No. 1862 an' C the Rules and /Regulations of the San -Joaquin Local. Health District. <br /> ?> <br /> JOB ADDRESS/LOCATION >I DV J /C . _ <br /> j f a �� CENSUS TRACT <br /> Owner's Name Phone , <br /> Address City . . <br /> .r. i <br /> S / <br /> Contractor's Name W /f.�GLK.' +�/�ir�?i�5 License #-ko2ace Phone !J i <br /> TYPE OF WORK (Check): NEW WELL _/Y, DEEPEN -/? RECONDITION '/? DESTRUCTION /^T <br /> PUMP INSTALLATION'( PUMP REPAIR,/7 PUMP REPLACEMENT r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing <br /> .Irrigation Gravel Pack-- Depth of Grout Sea] <br /> Cathodic Protection 0;7 Rotary Type of Grout .tel <br /> Disposal Other , Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .o€ Pump / H.P. Z� <br /> N4 <br />, PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />, TIES TRUCTION0_ F WELL: Well. Diameter Approximate Depth <br /> Describe Material, and Procedure k <br /> lI 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 anew well, I will furnish the .San-Joaquin-Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before .putting the.-well in-use.... -the above <br /> information is true to-tthe•best-of-.my..knowledge and belief. I WILL CALL ,FOR A GROUT INSPECTION <br /> PRIOR TO GROU INC ' A FI P CT <br /> 'SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I ' DDG DATE -�-� _ <br /> ,;APPLICATION ACCEPT 2_ <br /> f ADDITIONAL COMMENT �7 rr <br /> PHAS 0 INSPECTION PHASL III/FINAL INSPECTIO <br /> INSPECTION BY XW. Al DATE T INSPECTION BY DATE <br /> R H IL26 (12Y- 1Z �� ! 2 <br />