Laserfiche WebLink
V160I.., E. <br /> SAN JbAQUIN'�•LaCAY HEALTH DISTRICT <br /> OF .OFFICE FTSE: Hazelton Ave. , Stockton, Calif. <br /> Telephone: (203) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'1 <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application ie 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 OrdinaiG:ce No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> - <br /> JOB ADDRESS AbCAT ION T, i CENSUS TRACT <br /> r. <br /> Owner's Name f� I/f N CfZCSi'U ,� G L UB Phone <br /> Address ` ! /,v, //z eG*/z-:1eCity 7/�i�--�� . 64-1 <br /> Name ame /✓�%✓� �i�4 S, D,�%L L.:�/� <br /> - � . ..,,.,..,_ License #ZZaPhonesZZr/�3l <br /> TYPE OF WORK (check): NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7—pump REPLACEMENT /7 <br /> Other `_` <br /> / <br /> I, <br /> / - <br /> DISTANCE TO NEAREST: SEPTIC TANK/ LIVES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' .PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Yll 4 s TiG <br /> Domestic/public Driven Gauge of Casing MjO.p/;/-L. <br /> Irrigation Gravel Pack Depth of Grout Seal S`D <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed '—By: ` <br /> PUMP INSTALLATION., / Contractor <br /> f Type of Pump H.P. <br /> PUMP REPLACEMENT: . /% State Work Done o 6^ 7y 7 <br /> f7 <br /> PUMP, .REPAIR: /7 State Work Done r <br /> �• I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth O ' <br /> I° Describe Material and Proc lure <br /> �j- LSE 1- U a <br /> �2 <br /> I hereby agree to comply with all laws and regulatio s of the San Joaquin Local Health District <br /> and the Statei ;iof California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after comple•ti!on of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS11REPORT 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 LOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY Gr/ DATE ' �- O <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 44IIF INSPECTION <br /> INSPECTION BY DATE /�--7 INSPECTION BY DATE — 9-7b <br /> rl � ��7G I.n___ Y S/ UJV/f�V V{/ ,•ra /Y`W�... / '.' .�U fR'4� ! • I_� � <br />