Laserfiche WebLink
Te -4 --,4 *,1 i t p "7 �- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Z_ ?o ewN40,z- <br /> FOA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ? e <br /> Telephone: (209) 466--6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Db <br /> THA PERMIT 'EXPIRES ]. YEAR FROM DATE_ ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to I 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. 1$62 andlIthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - i "NSUSU/S� NSITRACT <br /> Owner's Name f}�('y� Phone <br /> Address SAM ry it _ City <br /> Contractor's Name S�.L� '_ ^I, License - -Phone <br /> �� <br /> TYPE OF WORK (Check)::: NEW WELL / / DEEPEN / / RECONDITYONT/ ,[,--DESTRUCTION, _ <br /> � -x PUMP INSTALLATION / / PUMP REPAIR / / ,, PUMP REPLACEMENT f / <br /> ..ocher I l �I`L.L Ftp ,�JZI G�IZ/ar+/ GJ''�G[� G✓��=/� �!'f}�s/,a 9� <br /> DISTANCE TO, NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY G✓��L � G�?/f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C�iyT <br /> 1 PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, 1 Cable Tool Dia, of Well. Excavation <br /> DOMES t:ic/private I Drilled , Dia, of Well Casing <br /> Domestic/public Driven-: ... _ <br /> ` Gauge of Casing o ' <br /> v � <br /> Irrigation r Gravel Pack, Depth of_Graut Seal Q <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal ! Other Other-,-In-formation <br /> Geophysical ,j Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done fi <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Di4'aineter`-�.� Approximate Depth <br /> Describe Material aiid-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 t <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 puttingthewell 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_FI.NALr INSPECTION <br /> SIGNED X2!2y; ' _ _ TITLE <br /> - (DRAW_PLOT PLAN ON REVERSE ,SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ;BYDATE <br /> r- <br /> ADDITIONAL COMMENTS: _ I <br /> PHASE II GROUT INSPECTI N P SE /FIN SPECTION <br /> E INSPECTION BY DATE Al 7 INSPECTION BY DATE � <br />