Laserfiche WebLink
i <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> FOF_ OFFICE USE': t '•r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. —2Z- <br /> 7;7-R/ <br /> 2Z-77-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 i <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 <br /> 11 Joaquin Local Health District. f <br /> JOB ADDRESS/Lee*TtBN1_ ij�_ CENSUS TRACT <br /> Owner's Name Phone y'3Z— -3 6 <br /> Address City <br /> Contractor's Name <br /> V1.. � License #W49L Phone <br /> . I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK r' SEWER LINES �` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINOBO RIVATE DOMESTIC WELL JBLIC 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 Driven Gauge of Casing '' <br /> Irrigation a <br /> g Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of GroutJ_�--- <br />-Disposal Other Other Information <br /> Geophysical, Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> s t Y <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 1 <br /> after completion of my work on a new 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED _ E <br /> (DRAW PLOT P ON REVERSE SIDE) j <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY ; <br /> � <br /> APPLICATION ACCEPTED BY DAT F,--- •�.4 17 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTI N"BY—""" DATE INSPECTION BY ^'`—DAT E._ <br /> -(a�,�„�( � �K � ����..:;� -= �y�"��+v0�-�--�..'�'• II <br /> R 14 A)C, 13— z /G_'7A - o _a _-2M <br />