Laserfiche WebLink
I I--- - -I'- . t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> F0F OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. G <br /> r Telephone: (209) 466-6781 x , `/(/� <br /> APPLICATION FOR WELL CONSTRUCTION OR`PUMP PERMIT Permit No. 77�� 4 J� <br /> M <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0 _0 ' <br /> / <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. ��nd the Rul and Regulationsofftthe San Joaquin Local Health District. <br /> JOB ADDRESS/L ION �✓ "tel `-' CENSUS TRACT <br /> Phor{� <br /> Owner's Name Cr 117& <br /> // <br /> /I \ r�... <br /> Address [Vy Cit <br /> Contractor's Name License/4. 3173Phon 'l7l� -' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / � RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR /A—PUMP REPLACEMENT /_ <br /> Other / /. . 7— <br /> DISTANCE TO NEAREST: SEPTIC TANK ySEWER LINES PIT PRIVY , <br /> • SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "\ <br /> Industrial ., Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> (Cathodic Protection Rotary Type-of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: F) State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby agree to comply with all laws and ,regulations of the San Joaquin Local Health District <br /> land the State of California pertaining 'to or regulating well "construction. Within FIFTEEN,DAYS <br /> rafter 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 9 J�, d <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,!/ - '7 <br /> 1/77 _ 2M <br />