Laserfiche WebLink
SAID JOAQU'IN LOCALzHEAt- 1-QH DISTRICT <br /> OROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S:,t1� CJ <br /> I[ THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued / -17-7.5- <br /> ' - (Complete In Triplicate). <br /> Application is hereby 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 District. , <br /> j .TOB ADDRESS/LOCATIONU, )0a4vVi <br /> CENSUS TRACT <br /> 01 <br /> Owner Q s Name t Phone -FL,-L3 -- <br /> Address �' -� %" � City <br /> L-�rr., <br /> Contractor's Name (� cense c 9a8Io3 Phone-S.')--2--/03/ <br /> ;,TYPE OF WORK (Check): NEW WELL / µDEEPEN 1-T RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP, REPAIR / / PUMP REPLACEMENT w <br /> Other /% _ h� _ <br /> >,DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES ` �' ._ PIT PRIVY <br /> SEWAGE DISPOSAL,FIELI] 1 CESSPOOI:/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIG-IWELL `�/ PUBLIC DOMESTIC WELL � <br /> INTENDED USE-' -{ TYPE OF WELL \ 1 CONSTRUCTION SPECIF-ICA'T'IONS r <br /> industrial Cable•'Tool W,,Dia. of Well' Excavation <br /> Domestic/private 3 Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Cas'if:g _ . �' /117 <br /> Irrigation Gravel Pack -N. -Depih of Grout-ISA-al <br /> Cathodic Protection _ Rotary Type. of_Grout'l.'-: <br /> Disposal Other ®thir Information. <br /> Geophysical ;�F ., s Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump IN � ! H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP-,,REPAIR: / / State Work Done <br /> ES•TRUCTION OF SWELL. *WeII Dat eteic "` ` �`., - = -� `"" 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 regulat`iag'well construction. Within FIFTEEN DAYS <br /> a 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 puttingthe-well in.use.. The above <br /> information is true to the-best of my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A, FINALwz-4NSPE&46N- - <br /> SIGNED TITLE <br /> (DRAW -PLOT PLAN ON REVERSE SIDE <br /> • } FOR DEPARTMENT USE ONLY <br /> i..� PHASE I ���L <br /> [4 APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P =_ q E tW GROUT INSPECTI u :. . :; PHASa <br /> /FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE - S <br /> � " _E H 1426� • Rev. 1-7,4.. <br /> 1-74 2M , = <br />