Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FAR,OFFICR USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Tzl--S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Id-1ol-71¢ <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 application is made in compliance with San Joaquin . <br /> County Ordinance No. 186 Rules and Regulations of the San Joaquin Ljcal Health D stri t. <br /> /�urS <br /> JOB ADDRESS i±OIQ r CENSUSVMCT <br /> Owner's Name ::7-( e-, ,( 1 G/ d�- Phone <br /> Address City <br /> Contractor's Name -y LIU d I Js ;r License #77 76 Phone <br /> TYPE OF WORK (Check): NEW WELL )(T' DEEPEN -/-T RECONDITION /-7 DESTRUCTION f7 <br /> AL <br /> PUMP INSTLATION A7 PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> 0-Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �L� SEWER LINES PIT PRIVY r� <br /> SEWAGE DISPOSAL FIELD GTS£PA9W4EEPAGE PIT lao_ ,F- OTHER <br /> PROPERTY LINE'(-' PRIVATE DOMESTIC WE7LZd0f'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing L <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t \j <br /> Cathodic Protection _ Rotary Type of Grout M , . ^� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ;. <br /> ,Type of Pump17 <br /> H.P. <br /> PUMP REPLACEMENT: % / State 'Work Done <br /> PUMP :REPAIR: /- • State Work Done _ <br /> f <br /> REES•TRUCTION OF WELL: Well Diameter Approximate Depth AS, <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 /> 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 INSPECT O / <br /> SIGNED <br /> KDRAV PLID7 PLO ON REVERSE SIDE <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY, DAT Z- fe <br /> ADDITIONAL COMMENTS: 41,yllS Am <br /> PHASE 4I4GROUT INSPECTION fv, U PIRAgE III FINAL INSPECTION <br /> INSPECTION BY DATE c9, a ?S INSPECTION BY DATE /.2- <br /> E <br /> E B 1426 Rev. .I-74 � 1-74 2M.-` <br />