Laserfiche WebLink
D � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S S3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> i� � <br /> t (Complete In Triplicate) H <br /> Application is hereby made to the San Joaquin Local Health District for a permitlito construct <br /> j- and/or install the work herein described. This application is Made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local :Health District.. <br /> JOB ADDRESSAOCATION �aoa ' �.,r ` <br /> p_. fo OprSl��sy, fi�0 440 6r-&d�I Pit CENSUS TRACT <br /> Owner's Name rr o a :oma 37.ASGhe ry A&Wd ?r,aao, `7 <br /> �C.; <br /> ne <br /> Address City ' <br /> Contractor's Name p�i u.- License , ��hlone 'X74 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN'/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/? PUMP REPLACEMENT /?. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY '' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i Lv <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 <br /> 2_ Domestic/private Drilled- Dia. of Well Casing iC <br /> Domestic/public Driven Gauge of Casing iM <br /> Irrigation Gravel. Pack- Depth of Grout Seal iM <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ I _ <br /> Geophysical Surface Seal Installed B ii. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H:P. <br /> I _ <br /> } PUMP X/ State Work Done <br /> .. k.9 <br /> PUMP. .REPAIR: / / State Work Done - ff <br /> �I <br /> DES4TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure f <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 "I <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. in use.. !'The above: <br /> information is true to the-bIINSPE <br /> of m ..know d "nd belief. TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IO <br /> SIGNED ITLE � ,f' <br /> RA T PLAN ON RE RRSE SIDE <br /> R DEPARTMENT USE ONLY # <br /> PHASE I' <br />� APPLICATION' ACCEPTED BY DATE lG S <br />( ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE IIV ITSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 /*rG �M <br />