Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. o. <br /> Oh,OFFICE USE: Telephone: (209) 466-6781 Permit NO <br /> �� ION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> THIS PERMIT EXPiRES 1 YEAR FROM DATE ISSUED <br /> (Complete Ir► Triplicate) rict for a permit to construct <br /> lealth <br /> ith <br /> Appli <br /> cation is hereby mmde to the San Joaquin Loca111catiot: istmade in co plicna�Neal hSDistrictn <br /> ulations of the Sae Joaquin Lo <br /> and/or instal]. the work herein described. T sap <br /> ,'County Ordinance No. 1$6 an the Rules and Reg CENSUS TRACT <br /> JOB ADDDREESS/LOCATION '3'-4 L <br /> Phone - <br /> A) 11 <br /> 1n r <br /> Owner's Name city ' <br /> V 4 a <br /> Address Q 2 -t 35/7 <br /> � <br /> --License <br /> �' icense Phone <br /> Contractor,s Name <br /> "� DEEPEN /� f RECONDITIOI �T DESTRUCTION I�T <br /> TYPE OF WORK (Check) . NEW WELL /TALLATIN --- . per REPAIR I � PUMPREPLACEMENT <br /> PUMP INS <br /> Othe�r. l <br /> SEWER LINES _ <br /> -,PIT PRIVY <br /> DISTANCE OTHER <br /> TO NEAREST: SEPTIC TANK 0 _ <br /> `SEWAGE,DISEOSAL�FIELD"^""""'�CESSPOdI:ISEEPAPUBLIC FOMSTIC WELL— <br /> Ci <br /> PROPERTY LINE - PRIVADOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFI�CATiONS <br /> INTENDED'USE ,, � =Cable4Tool" ---` Dia. of Well Excavation <br /> _ Industrial Drilled Dia. of Well Casing <br /> gestic/private Driven Gauge of Casing <br /> .. Domestic/public --•-�--- Gravel Pack Depth of Grout Seal <br /> Irrigation s ;/Rotar Type of Grout c <br /> t Cathodic Protection , Y�' Others , Other Information <br /> —Disposal <br /> ' � Geophysical - Surface Sea]. Installed .B <br /> PUMP INSTALLATIONS Contractor _ S.P. — <br /> Type of Pup <br /> F <br /> PUMP REPLACEMENT: L_/— .State Work Done <br /> Pump -.REPAIR: ./ -/ State Work Done <br /> ► Approximate Depth _,, <br /> F DESTRUCTION OF WELL: Well Diameter <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 ori regulating well`construction. <br /> Within FIFTEEN DAY% <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health Distriel <br /> r 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 /> t SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE I <br /> ! 'APPLICATION ACCEPTED BY DATE <br /> . ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> :INSPECTION BY DATE INSPECTION BY �2e _ DATE <br /> 2M <br /> lz -a IL7Fi Rs.tr_ 1-74 <br />