Laserfiche WebLink
SAES JOAQUIN LOCAL HEALTH DISMCT <br /> PqE <br /> OFFICEIISE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT Permit <br /> f <br /> THIS PENT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J I <br /> {. �.�v✓'ry K l ca4--�4° (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District far a9p 2� . d6 <br /> o construct <br /> rmi <br /> 1 and/or install the work herein described. This application is made in campiiancetwith San Jopquin <br /> Conn _Ord' �j No. 862 end t tions of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATI � <br /> CENSUS TRACT <br /> - <br /> Owner's Name <br /> Phone <br /> Address 2 2 IfA1111 A !?b/ _D <br /> (i � City �W VW O p <br /> Contractor's Name �..ftk WELL � � 41 POf) _ License # <br /> o ZP'hone 2 <br /> TYPE OF WORK (Check). <br /> NEWW= a <br /> / DEEPEN I / RECONDITION /_7 DESTRUCTION <br /> PII!!P IA➢ST ION f J/ PIINP REPAIR / /I P[iMP REPLACM(ElT 1 j <br /> -Other-/—/— <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ' SEIFER LINES - PIT PRIVY <br /> 1. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T <br /> PROPERTY LIM PRIVATE DOW.STIC WELL PUBLIC DOMESTIC WELL � fl <br /> QED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Domestic s �ble Tool Dia. of Well Excavation 2 <br /> /privates"� ' +' Drilled Dia. of Well Casing Zle <br /> esti/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> )Cathodic Protection Rotary <br /> /Disposal Other �a of Grout <br /> Other Information <br /> / Geophysical <br /> Surface Seal Installed By-:- <br /> Pump <br /> :PUMP INSTALLATION: <br /> Contractor ; <br /> Type of Pump H.P. <br /> PUMP REPI.ACEMM: / / State Work Done <br /> PUMP °REPAIR: k / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter C <br /> Approximate Depth � <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San oa uin Local Health District <br /> 4 , <br /> and the State of Californiafornia pertaining to or regulating we11"°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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED <br /> TITU­- <br /> (DRAW <br /> E -(DRAW PLOT PLAN ON REVERSE SIDE) ; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ w , ^:, , ; DATE­ - <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> LNSPECTION BY DATE INSPECTION BY DATE -78_ <br /> �E H 1426gen_ 1_74 /�° 11-7-7 Our <br />