Laserfiche WebLink
I I C�'Ac:� <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�rOFFICE USE: 1601 E. Hazelton Ave.., Stdckton, Calif. <br /> I Telephone: ' _'(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y_3 774 <br /> THIS PERMIT 'EXPIRES,.I-YEAf�R.:F7RQ•M,,DATE ISSUSD Date 1asued 2r_7cf <br /> is iI` - .-• r •.({i�,mplete.`In_1r .�11Cat�j <br /> Application is hereb made to. the San Joaquin:1 caj;.rRealth,.DJst#ct, for a;,;permit to..cohstruct <br /> and/or.1estall the w rk;.herein descxibed,_ This application res 4aaade 3n ;compliance:with ,San Joaquin <br /> County Ordinance No., 1862.:nnd; the Rules.,and Regulations of.the:: a4;Joaqu u . Lacal .:$ealth ,District. <br /> L ...: <br /> JOB ADDRESS/LOCATION.,. Z111A _ ,t -.CENSUS.TRAGT <br /> r9 <br /> Owner <br /> °s Name <br /> Phone ?93 <br /> t FL b'Sd <br /> Contractor's .Name License . f,2a7.2 Phone <br /> TYPE OF WORK (Check): NEW WELL 'P7 DEEPEN RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� H,PUNP REPLACEMENT /f <br /> Other /% — <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT._ OTHER toPAM <br /> PROPERTY LIME PRIVATE DOMESTIC WELL 1�UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL l..,... . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Y Dia. of Well Excavation <br /> .Domestic/private i . Drilled Dia. of Well Casing <br /> IL <br /> Domestic/public � <br /> Driven - Gauge of. Casing,. o ry <br /> ;Iz`ri atioti ..'- ..... �. - <br /> g �'- `Gravel Pack Depthofof Grout Seal <br /> Cathodic-Protection - --i-�- Rotary , ., Type--of,.G'rou't <br /> . �:. ... <br /> p sal 1 Other Other Informat on '— <br /> Geophysical t w 'Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump :t, H.P. <br /> PUMP REPLACEMENT: j/17 jState Work Donees . <br /> PtJ1�r:REPAIR: _= /"� <br /> .State WorkDoie. <br /> „r <br /> ESTRUCTION OF WELL: Well FDiameter' <br /> —�---- Approximate Depth <br /> Describe-Material-and-Procedure <br /> I hereby agree tocomply .with all laws abd 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. myknowledge and belief., I WILL CALL FOR A.'GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSPECTION. <br /> SIGNED, 4ad 91f& TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE <br /> �0 ARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED *DTE `? Z Z 7 <br /> ADDITIONAL COMMENTS: <br /> a PHASE II GROUT INSPECTION MiSEI FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION SY DATE <br /> - f <br /> E H 1+26 <br /> Rev. 1-74 �. :-7L 9u <br />