Laserfiche WebLink
f Ja r r <br /> SAH' JOAQUIN, LOCAL WiEALTH DISTRICT <br /> FOErOFFICE USE; 1601 E. Hazelton Ave. Stockton Calif, s f` <br /> Telephone (209) 4666781 = <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. -Z-Z- 279 <br /> 9 <br /> THIS PERMIT. EXPIRES 1-YEAR FROM DATE ISSUED Date Issued =L `' <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-applicatioin -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 /> JOB ADDRESS/LOCATION �_ ,� jo CENSUS TRACT <br /> 9�L t O U rsE .4V A7- a <br /> Owner's Name _M4/V TECH EY) SC//QQ 4 6/5T-, . . Phone W 2 3 7111 <br /> Address'-. - /�'0, Anx 32 /ha&zT 'CA .�- „ : _._ City /11A,417FC,g <br /> I <br /> Contractor's Name d/a,Ac!c e06Z&22„ 7lUG_,.._.__. License #AD47gy Phone qy fig/rJ <br /> TYPE OF WORK (Check): NEW WELL 1Z DEEPEN/? RECONDITION /� DESTRUCTION /7 r <br /> PUMP INSTALLATION ) - PUMP REPAIR /7 PUMP 177vREPLACEMENT . , -' a <br /> Other , <br /> DISTANCE TO NEAREST: SEPTICYTANK' SEWER LINES P.IT <br /> tSEWAGE DISPOSAL FIELD- `' CESSPOOL SEEPAGE PIT ” OTHER\ <br /> PROPERTY-'LINE - PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r.. ._ TYPE"OF_WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial T��"'"' Cable Tool Dia. of Well Excavation lei% <br /> "A Domestic/private briiied Dia. of Well. Casing •, � � ��� <br /> Domestic/public � Driven � Gauge of Casing /2 C.,A, .-. <br /> l Irrigation �-� � Gravel-.Pack v Depth of Grout^Seal <br /> -- <br /> athodic Protection Rotary -T"' of GroutT�N1, �+E <br /> .� <br /> isposal Other'`' . Other Information <br /> Geophysical Surface Seal Installed B O <br /> PUMP INSTALLATION: Contractor A10,4k /—VC <br /> Type of Pump SCJBiyi E�S/BGE. _ . � A.P. Z A,00 <br /> t PUMP REPLACEMENT: / / State Work Done,) ' <br />} PUMP ,.REPAIR: " i s /-7- State Work Done <br /> E&TRUCTION 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 /> r 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 GRO NG A11D A AINAL INSPECTION.' ? t <br /> SIGNED TITLE <br /> (DRAW PLOT 'PLAN ON REVERSE SIDE) , <br /> FOR•_DEPARTMENT._USE_ONLY <br /> d <br /> PHASE I �� n <br /> APPLICATION ACCEPTED BY : DATE a_ <br /> ADDITIONAL COMMENTS: \ , <br /> i PHA II 5EOUT INSPECTION \ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 <br />