Laserfiche WebLink
�. 0,j,;;447 <br /> �� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR UFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �a•5° ���� <br />+ <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ-L1.P_31,_1 <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued ��Q/ <br /> (Complete In. Triplicate) .. <br /> Application is hereby made to .the San Joaquin 'Local Health District for. <br /> permit to construct <br /> and/or 'install the work herein described. This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 and the Rales and Regulations of the Sa ' -Joaquin Local Health District. <br /> 4 <br /> JOB ADDRESS/LOCATION / CENSUS TRACT : <br /> .; <br /> Owner's Name Phone (F2 <br /> cS 2- 7 <br /> Address City, <br /> Contractor's Name -License #apo- 42�PhoneT­� - ' . <br /> " y...ra�'^.w--aw.-'.'mr,"' '-�`. ' saw.--.�. . r_.�e.�wc_+.-,,,w.--_—....._ _... ,. .-•_T��-.-.'.rail .. _ _ _ __. "_-l—,v,_-+tee <br /> TYPE OF WORK (Check); NEW WELL j DEEPEN •/'' RECONDITION% f DESTRUCTION f7 <br /> PUMP INSTALLATION J, PUNP REPAIR 'J 7 PUMP REPLACEMENT <br /> Other L7 <br /> DISTANCE TO NEAREST SEPTIC TANK ' <br /> i SEWER LINES PIT PRIVY :-' <br /> A , ! I t. /, .rte— '. <br /> SEWAGE DISPOSAL 'FIEI.D CESSPOOL/SEEPAGE PIT i OTHER <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL' . PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS E <br /> _ a Cable ToolDia. of Well Excavation f <br /> Domestic/private Drilled Dia. of Well Casing �, L <br /> Doi�stic/publfc Driven <br /> Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br />-Disposal � � Other <br /> Other In <br /> Geophysical Surface Seal Installed Rv• � r i <br /> PUMP INSTALLATION: Contractor <br /> Type,.of `.Pump <br /> fI 4 <br /> PUMP REPLACEMENT: . . C/ State Work Done A <br /> PUMP :REPAIR:..., _-- _f-T_�S.tate•. Work Dome <br />)ES4TRUCTION OF WELL: Well Diameter App <br /> proximate Depth <br /> Describe Material and Procedure r <br /> C hereby agree to comply with all laws and regulations of this San Joaquin Local Health District i <br /> Ind the State of California pertaining to or regulating well '.const_r_ucti' ;Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish_, the San Joaquin Local Health District a <br /> TELL DRILLERS REPORTno£ ..the well and notify-them before '`' <br /> Lnformation is true- to the•best-of- Putting.`the-we'lI�-iri#use_... .The above <br /> my and belief: .I WILL CALL OR A GROUT INSPECTION <br />'RIOR TOG OUTING AND FINAL INSPECTION. , <br /> UGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY F <br />'RASE I <br />►?PLICATION ACCEPTED BY (p 7� <br /> ODITIONAL COMMENTS: - DATE <br /> PHASE GRo INSPECTION Of o <br /> NSPECTION BY PHASE FIN INS? ION <br /> DATE �l�� 7-]. INSPECTION $Y,Io� DATE 7 <br /> &..g 1426 Rev. 1-74 _ <br />