Laserfiche WebLink
r SAN JOAQUIN LOCA)r HEALTH DISTRICT <br />=yh P'FI 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 ? f <br />(Complete In Triplicate) <br />.pplication is hereby made to the San Joaquin Local health District for a permit to construct <br />nd/or install the work herein described. This application is made in compliance with San Joaquin <br />ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br />08 W ADDRESS/LOCATION �kVMCI%3% YA! 0% 6G71[LLC.3V T..3s. A75e- <br />S. �1 L'A�FJf) /)! P :�7Y- a)rsf c)F'%1P1-QUYN VS TRACT � <br />wner's Name <br />ddress <br />)U. �C (7 <br />_Vt'L`z ' - Phone ' —� Q . <br />City <br />ontractor's Name XL//.1'222 C/I•J �((()C7( '_ %Ae, License 0 .VJAQgb Phone..�Z/� <br />YPE OF WORK (Check): NEW WELL Y/ DEEPEN / % RECONDITION /% DESTRUCTION % <br />PUMP INSTALLATION / / PUMP REPAIR /--/ PUMP REPLACEMENT /_7 <br />Other / / __ -- _ 1 <br />ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRTVY <br />SEWAGE DISPOSAL FIELD- Cb:SSP001./SEEPAGE PI'!' OTHCR/tu_ j20C�.� <br />PROPERTY LINE - PRIVATE nnnarcm­ -- <br />_ Industrial <br />_ Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />_ Disposal <br />Geophysical <br />INSTALLATION: <br />JMP REPLACEMENT <br />1MP REPAIR: <br />:STRUCTION OF WELL <br />TYPE OF WELL <br />Cable fool <br />Drilled <br />Driven <br />Gravel Pick <br />Rotary <br />Other <br />Contractor _ <br />Type of Pump <br />State Work Done <br />State Work Done <br />DOMESTIC WELL <br />SPECIFICATIONS i <br />Ilia. of Well Excavation <br />Dia. of Well Casing <br />Cauge of C tsi.ng _ -- <br />Depth of GroutSca:l <br />J <br />Type of (rout 11�r1t�� <br />Other Information <br />Surface Seal .Cnsta. <br />Well Diameter _ Approximate Depth <br />Describe Material and Yroccdurc <br />hereby agree to comply with all laws and regulations of the San .loag0.n Local Health Distrl.ct <br />id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />[ter completion of my work on a new well, 1 will furnish the San Joaquin Local health District a <br />_'Ll. DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />iformation is true to the best of my knowledge and belief. 1 WILL CALL FUR A GROUT JNSPECT'LON <br />:10R TO GROUTING AND A INSPEC'LON <br />CGNED r., Ill yC l�/LCC _ TITLE �v�t <br />WR Ata Pi )T PLAN n CVF.RSE SIDE.) <br />IASE I <br />'PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: <br />PHp$E Iii, <br />VSYECTION BY <br />E 11 149h a,,,, 1-71. <br />FOR DEPARTMEKT USE 0_NI.Y <br />DATE _1 J <br />--5-_ 7- INSPFCI'ION <br />Pl1ASE LII/FINAL INSPEC�T,IQNN <br />