Laserfiche WebLink
_ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE:' 1601 E. Hazelton Ave. , ;Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-4/l�crJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) rq 7 .- tLco-e <br /> Application is Aereby 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-.,-1862.-and the Rules and Regulations of the San Joaquin Local Health Diet#ct. <br /> JOB ADDRESS/LOCATION �_y A41 CENSUS TRACT <br /> Owner's Name /1 Jr'/,c 1rEjZ 7 tl Phone <br /> Addressf Z�� dctt`c t _ City <br /> -� <br /> Contractor's Name Ar,�n i�l1 3��,� License #.U?/Ij phone - /S. IF; <br /> TYPE OF WORK (Check.) : NEW WELL -/y/ DEEPEN /-7 RECONDITION /7- DESTRUCTION:./ <br /> PUMP ,INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /-T <br /> Other / j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DINES PIT PRIVY � <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 Cable Tool - Dia.. of.-Well Excavation y ,• frio ! <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of G eal J v --_ k <br /> Cathodic Protection Rotary Type of rout <br /> Disposal Other Other In ation <br /> Geophysical Surf ace Seal Insta <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> y <br /> PUMP':REPAIR: ; / '--State"Work.Done <br /> DES•TRUCTTON 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true tothe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRICR TO UTING 4D A FI NS ON. r <br /> SIGNED. TITLE ,c <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> -HAS E I <br /> PLICATION ACCEPTED BY DATE <br /> A.DDITIONI1L .COMMENTS: JJ <br /> PHASE ROU INSPECTION HA E ( N INSPECTION <br /> INSPECTION By&1A DATE 77 INSPECTION BY DATE i <br />