Laserfiche WebLink
��20` .-I- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE`USE-- 1-4'1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) t <br /> Application is herebymade 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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 2 �1 3 I <br /> Z2,00f d CENSUS TRACT r. <br /> h:� f <br /> Owner s Name ZO a iv A,) Phone <br /> Address _:--City i <br /> Contractor's NameLicense #X2, 1/y Phone <br /> b _ _. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / � DESTRUCTION /_7 . <br /> PUMP INSTAL ATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK�AaQ! SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE' DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> ,Industrial 4. Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing r. w <br /> } Domestic/public Driven Gauge of Casing <br /> Irrigation - -Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary hk Type of Grout <br />�-Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> .: <br /> PUMA' INSTALLATION: Contractoror <br /> = + F r'Type'"of;Pump H.P. S0 <br /> PUkT REPLACEMENT: f` w <br /> State Work Done � � <br /> PUMA; :,REPATR--:-- . -1-F/—State-Work=Done <br /> TRUCTION OF 4ELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure € <br /> �reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> `he State of California-pertaining- to or regulating wel1 ''construction. Within FIFTEEN DAYS <br /> completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'RILLERS REPORT of the well and notify them before putting the.-well in use. The above <br /> ;tion is,k.true to thest f y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> G AFI S ON. <br /> TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> � 1 <br /> ACCEPTED BY DATE t <br /> )MMENTS: <br /> PHASE IT GROUT INSPECTIO PHASE,�Jjg/FINAb INSPECTION j <br /> DATE INSPECTION BY ATV61- 7 f <br /> °v. 1-74 1/f77. 2M <br />