Laserfiche WebLink
Ls to tJ — P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • FORf'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �€ <br /> Telephone: (209), 466-6781 <br /> ►� ,,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ate_ c/s-84} <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9-t7-Tc/ <br /> (Complete In Triplicate) f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to ' <br /> �oconstruct, <br /> and/or install the work herein described. This application is made in compliancel�with-san Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local-Health District. <br /> JOB ADDRESSft@e*tlQNI� <br /> CENSUS TRACT <br /> Owner's Name,' Phone -7 <br /> Address <br /> City <br /> Contractor's Name s License # ` 69'4 Phone fe/�-3Z1 Q <br />�l TYPE' OF WORK (Check): `NEW WELL / DEEPEN -/-7 RECONDITION /? DESTRUCTION /71� <br /> PUMP INSTLATION % PUMP REPAIR /� PUMP REPLACEMENT <br /> ;Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES PIT PRIVY <br />;. <br /> SEWAGE DISPOSAL FIELD' <br /> EB <br /> C &gegblSPAGE PiT DDS` OTHER <br /> i PROPERTY Z /-?PRIVATE_ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic rivate g ell. <br /> � - /P -�---�--- � - :Drilled- -- ....A.,..-Dia.-ofrtWell-Casio __.. - <br /> Domes-.ticlpublic ,; Driven Gauge of Casing <br /> Irrigati' 'r' �.. Gravel Pack Depth of Grout Seal /I <br /> Cathodic Protection-'T Rotary ":Tyge�, of' Grout -5�=jaa ,T <br /> Dispodal <br /> f° Grout , <br /> Disposal ( Other Other Information �►. <br /> Geophysical Sur-face Seal Installed By: <br /> traCtOr � <br /> PUMP INSTALLATION: � �Contractor �r J- ,_,..,..._. <br /> k. Wl Q/{. S (v �` <br /> 4ype5-of_P-ump !i H.P. <br /> PUMP REPLACEMENT: `%/ ' State,Work Done <br /> PUMP ,.REPAIR: .. tL�y Statie�'Wvrk Done <br /> ES-TRUCTION OF WELL:,/ Well Diameter Approximate Depth - <br /> Describe Material -and Procedure �I <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 o€ the well and notify them before putting..the. well in.use.. The above <br /> information ,is true to the-best -of my.knowledge and belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A` IN INSPECTION. I� <br /> SIGNED TITLE <br /> .,PLAN-ON-REVERSE SIDE M <br /> ` IFOR`IDEPARTMENT USE ONLY <br /> PHASE I �� w IM <br /> APPLICATION ACCEPTED BY� k DATE <br /> 7 <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTIO PHASE INAL INSPECTION <br /> j INSPECTION BY DAT INSPECTION- BY <br /> E H 1426 Rev. 1-74 1-74 2M <br />