Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE O�TICE 'USE: 1601 E. Hazelton Ave. , Stockton, Calif,. <br /> Telephone-: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-1112-' <br /> I <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 1-3L' <br /> (Complete In Triplicate) <br /> I <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 Jopquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION FA ��Q1iLt- j SVIV".4/--,&ENSUS TRACT <br /> Owner's Name M 3, �+ �^ Phone <br /> Address a <br /> City I <br /> Contractor's Name 3-f i .vL� License 1t J177X ,PhoneyT- 32_ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /? RECONDITION /_7 DESTRUCTION /- } <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 i <br /> Other <br /> DISTANCE-TO NEAREST: SEPTIC..TANK ..SEWER.LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELD 5�_ f-CESSPOOL/SEEPAGE PIT - OTHER --'- <br /> PROPERTY LINE - PRIVATE DOMESTIC WEL PUBLIC_ DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> Domestic/private X Drilled Dia. of Well-Casing <br /> Domestic/public Driven lGatige of. Casing ... <br /> Irrigation Gravel Pack Depth ,of. Grout Seal f.._ <br /> Cathodic Protection Rotary Type of.'Grout e_ X &_ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 4 � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done y <br /> PUMP ,.REPAIR: a / / • State Work Done <br /> DES,TR_UCTION OF WELL:' Well Diameter Approximate Depth <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 />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> — _ - <br /> -'- L T-PM ON REVERSE SIDE) <br /> (�Je nlaU an b[t_W,O _� FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEMZD-BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> SE I GROUT INSPECTI P I/FINAL INSPECTIO <br /> INSPECTION BY DATE Jfj INSPECTION BY DATE ^� � <br /> R R 1LIA n .__ v moi. 1 .477 <br />