Laserfiche WebLink
— -' - - <br /> VPLllC6AOTSI'ON <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAiOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 FOR WELL CONSTRUCTION OR PUMP PERMIT Peirmit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <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. and the Rules and Regulations of *�,o <br /> San Joa uin Local Heal District. <br /> k ;�v � C F fl A-w sv-a <br /> J <br /> JOB ADDRESS/Loc �S'tP Ll-Zev <br /> CENSUS TRACT <br /> Owner's Name Al2/01 69,0 u (3 S -r- C'o t1q)hone Z�1 —4 Cv=0-4_ <br /> Address <br /> Contractor's Name License #,�S1d!p3 Phone ZY7— ,63CVz/ <br /> TYPE OF WORK (Check): NEW WELLIZTDEEPEN 17 RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION /��UMP REPAIR /� PUMP REPLACEMENT ! <br /> Other a <br /> DISTANCE TO NEAREST: SEPTIC TANK.' Q�y-SEWER LINES IT'PRIVY, <br /> SEWAGE DISPOSAL FIELDG<a CESSPOOL/SEEPAGE PIT. OTHER -----7 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'-i— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well,Excavation <br /> 70----Vo-­mestic/private Drilled Dia. of Well Caging <br /> I Domestic/public Driven Gauge of-Casing. � <br /> F Irrigation Gravel Pack Depth of Grout SeA , <br /> Cathodic Protection otary Type of Grout, <br /> Disposal -Other Other Information — _¢ <br /> Geophysical. ace Seal. Installed By: <br /> PUMP INSTALLATION: Contractor', � <br /> Type of Pu ° H.P. <br /> PUMP REPLACENENT: /% State Work Done`"" ` <br /> PUMP -.REPAIR: /7 State Work Done. ! - <br /> ,pES TRUCTION OF WELL: Well Diameter � Approximate Depth <br /> Describe Material and-Procedure <br /> I hereby agree to comply with all laws and regulations of theiSan,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 'in.use.. , The above <br /> info ation is true to the best of my knowledge and belief. I WILL CALL .-FOR A 'GROUT INSPECTION <br /> PRIOR GROUTING AN S CTIOAq. 11 ; " . 3 <br /> 5I TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 415_ 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT I SPECTION, �.f PHASE INSPECTION <br /> INSPECTION BY DATE7-2INSPECTION BY DATE & <br /> A; 1-74 2M <br /> i E H 1426 Rev. 1-74 � ' <br />