Laserfiche WebLink
_ SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOO+rOFFI.CE USE: 1601 E. Hazelton'Ave. , `,Stockton, Calif. <br /> Telephone: 1(209) '466=6781 i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- Aye <br /> THIS PERMIT EXPIRES 1-YEAR-FROM DATE ISSUED Date Issued 1 PL7 77 <br /> r (Complete.:-In Triplicate) , <br /> Applicatiou .is hereby made to the San Joaquin tocal:_Iiealth 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. 186622 and the Rules and Regulations :of. the Sara Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �a tE r CENSUS TRACT 4f4� <br /> Owner's Name VVLcIL V_ Phone <br /> Addresses )X110 0 City <br /> .-.-.e�--_, T <br /> Contractor's Name ?!' C-W License # Phone S- ; 7 ySC- <br /> TYPE OF-WORK (Check): NEW WELL /_T DEEPEN /7/ RECONDITION /� . DESTRUCTION /� <br /> Y; 4 PUMP INSTALLATION 1V PUMP REPAIR / J PUMP REPLACEMENT <br /> Other ! / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Too <br /> ...q, Dia. of Well Excavation ` <br /> .Domestic/private Drilled Dia. of Well Casing <br /> Dom stic/public Driven Gauge of Casing q <br /> rigatioil Grave i-hack" Depth of Grout Seal <br /> 'Cathodic Protection - —Rotary,-- -- -. .-w-Type-of-Grout'— ,_ .... <br /> Disposal R: Other Other Information <br /> Geophysical ' - Surface Seal Installed By: -- ' <br /> i <br /> PUMP INSTALLATION: Contractor � SJ„„ <br /> Type of Pump S�L b���rt H.P. 2 �3 <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP :REPAIR: ,.-w.. ., / State Work Done <br /> i` '2ESIRUCTION OF WELL: Well Diameter Approximate Depth -' <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sax: 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 my.knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �- � , . <br /> DRAW PLOT PLAN ON REVERSE -SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A6,e;gw= <br /> DATE <br /> ADDITIONAL COMMENTS: / <br /> 4-7 <br /> PHAS * Ij GROUT INSPECTION 11F NSPECTION <br /> F INSPECTION BY DATE INSPECTION . DATE <br /> pf JU <br /> t E R 1426 Rev. 1-74 1-74 2M <br />