Laserfiche WebLink
/ ' 'SAN JOAQUIN LOCAL HEALTH. DISTRICT ` <br /> FOH OFFICE USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. C <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-7-dX*;?J:1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 JS �, <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 /> e-o <br /> JOB ADDRESS/LOCATION _MS�P CENSUS TRACT <br /> 948 <br /> Owner's Name Phone XZS-40.22 I <br /> Address City <br /> slocktQn <br /> Contractor's Name I4ajt!a ^ G, _0aCk License # 200794 Phone ' 948...8817 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ J RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /r/--PUMP REPLACEMENT /7 <br /> Other / / <br /> WPI I- <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> W Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: --- <br /> PUMP INSTALLATION: Contractor _W21:tp-.. G,- Nhn-nk <br /> Type of Pump Pomona H.P. c,( <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-..REPAIR= -- — -_ / -/- -S ta-t-e•-Wnrk 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW <br /> PL77f PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k <br /> APPLICATION ACCEPTED BY _-; � � _ _ --- ---- DATE /y J7 <br /> 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C,13 DATE ..ELI /7`J <br /> E H 1426 Rev. 1-74 <br /> '� 3/76 2M <br />