Laserfiche WebLink
Page 9 of 26 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT: <br /> JOTDEFLCR C58: 1601 E. Nntelton Ave., Stockton, Calif. <br /> Telcphona: (209) 466-67SI <br /> APPLICATION EOR WELL CONSTRUCTION OR PUMP PERMIT Permit Not W <br /> 7 6 ;'Wlo <br /> - - - <br /> THIS PERMIT EXPIRES 3 YRAR FROM. DATE ISSUED Date Issued 4-.,2S_2-7 <br /> (Cosplete In Trtpiicate) <br /> Application is hereby soto the San Juaquin Local Health District f <br /> da or a permit to conatrwct <br /> and/a, install the work barein duscrib6d. This apPTleation is made in COMPILance with San Joaquin ) <br /> -.6 thr�RuXe and Regulations of the Son Joaquin Local Health District. <br /> County Ordinance No. 1862 e <br /> e" JOE ADDRESS/LOCATION /• /I7-1 T/ mAM '�`yP '� /�'"I cENSOS TRACT <br /> Owner's Have _ - /!cC r'�41 Phone / <br /> Address r.�7�7City <br /> Contractor's Name �' - .__. /. Licancc 6' °- GyPhone g�l - <br /> 'TYPE OF 6X= (Check) `TEM WELL l7 DFZPEZ I f RECONDIT"Iob DESTRUCTION <br /> YUIIP IkSTAII71:lON' PE'8+"REPAYR�1"`POlff"REPLFCEIlEN'T�" T Y t <br /> Other ✓�l i <br /> DISTAyCE TO NP,AREST: sEFI:IC TANK i£itER L1NaS �� PIT PRIVY _.-. <br /> SESiAaKJ)ISPOSgl�L,,FIELD CESSF00W$EEPAQR p1T OI}18R <br /> PROPERLY ERIVATE DOMESTIC WPL' -- PUBLIC :X1Mf3TLC WELL <br /> INTENDED USE TYPE OF WELL CDNSTRLCIION SPECIFICATIONS i <br /> Imdustvial cebie Tool Din. of Well Excavation d <br /> Domestic/private Drilled. Dim. of volL Caging <br /> 6. Doscsttc/Public — Driven Cause of Casing <br /> — Irrigation • — Gravel Pack Depth of Grout S <br /> _ eal - o <br /> CsthOdlc Protection- - Rotary Type of GrootDisposal <br /> Other Other Information <br /> � -� CeODhysicn.I S Yfatg Seal In■tailed EY' <br /> Adci <br /> PUMP INSTALLATION: Contractor.c.,. .,� '�' -— <br /> Type of Pump H.P. <br /> PU:1F RP;PLACENk'NT: / / State Work bona <br /> PUMP REPAIR: /7 state Work Dane <br /> DESTRUCTION OF WSLL:. Well Diameter Approximate Depth Eng <br /> Describe Material and Procedure <br /> I harvby ARree co comply with all laws and regulations of the San Joaquin Local Reslth District <br /> And the Stmce of California. pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wall, I will furnish the San JVAgwin Local Health District a <br /> WELL <br /> DRILLERS RSPOR7 �e wa11 and notify them before putting the wall in use. The obova <br /> inParwtlon la a eq the bear of m knowludRe and belief. II W.LL CALL. EOR A GROUT Iy5PLCTION <br /> PRIOR TO CRO ARDS' �j57 YON s ty <br /> SIGNED TITLE <br /> "" pRAW PTkF PLAb ON wmyise SID <br /> PDR D�,ARTMEN'I USE ONLY <br /> PHASE I PHASE IZ y I DATZ <br /> APPLICATION ACCEPTED EY _ ' <br /> ADDITIONAL CON?RL`1TS: ---m--.- PtLt5' I FT INSt' N <br /> NSPRCTIOH AT-E <br /> FN§PECTTON dY^figs-7'7 DATE IN5PFCTlON � <br /> _ V76 2M <br /> - E N 1426 Rev. 1-14 <br /> 11/10/2011 <br />