Laserfiche WebLink
E; <br /> i r <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a ,3076 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local !lealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqu:.t <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ p_ /1 0i,, O_:Ti= OF C`:Di. aD.IE,,ST CENSUS TRACT <br /> SIDE <br /> Owner's Name ;:",; ,. ,: ",I'-.,0 Phone 599-,694 <br /> Address 1Q?Eti ;,,;r,v" RL. City RIPON <br /> Contractor's Name _�f �1;Iii,S T OS. D;1L1rIN.1 :,0. ,INC. License 0 29081 Phone 522-1011 <br /> X00 <br /> TYPE OF WORK (Check): NEW WELL /X7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER(�t�-,3F, <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 22" (INU <br /> Domestic/private Drilled Dia. of Well Casing 14" <br /> Ilk <br /> Domestic/public Driven Gauge of Casing x,/16 GA <br /> X Irrigation - Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information ;LAF-,�,,'r 0:•;NER � <br /> Geophysical Surface Seal Installed By: - \ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> • _ J <br /> PUMP REPLACEMENT: / / State Work Dene C� <br /> PUMP .RZPAIR: /7 State Work Done \� <br /> DESTRUCTION 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 ir_ use. The above <br /> information is true to the bast of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -';:�TS �'i;Oc , Li. Li,l ;� ��.I;+C. BY TITLE --7r,_ �',��(1�c! SEC:1, � <br /> DRAW PLOT PLAN ON REVERSE SIDE ._._.l <br /> FOR DE?ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY FSS ; �i j DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHA II AL INSPEC'TION <br /> INSPECTION BY _ DATR INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />