Laserfiche WebLink
V/ SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FO—E,OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 721 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> 1700 i,(f p nr1 <br /> JOB ADDRESS/LOCATION 6 f eU 3S 1? 6 E CENSUS TRACT <br /> Owner's Name tr4em-s 7W 14 CG/ Phone F3 5-I -7 5— <br /> Address / 4 3 s C_0©4/,2GgZlqu - City <br /> Contractor's Name ,j29 ILC i,u Co . License # 257 8'2---Phone <br /> TYPE OF WORK (Check) : NEW WELL /-' DEEPEN /7 RECONDITION /DESTRUCTION /-7 <br /> PUMP INSTALLATION / J PUMP REPAIR /,`f PUMP REPLACEMENT f <br /> Other / rz ��-- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /Mate Work Done C a7p*q i e- <br /> - - 1h <br /> ,RES-TRUCTION_ OF WELL: Well Diameter 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 regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distract 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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TJXG, A FIN INSPECTION. / <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR_DALTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED—BY ,;; ``; % DATE <br /> ADDITIONAL COMMENTS: ._ <br /> E II GROUT INSPECTION P E I F AL INSPECTION <br /> INSPECTION BY DATE INSPEC BY DATE - -- S <br /> E H 1426 Rev. 1-74 1-74 2M <br />