Laserfiche WebLink
r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR EFFIGY USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ��- ?� cf l �3S <br /> Application is hereby made to the San Joaquin Local Health Distri4 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 dJooa�quuin Local Health District. <br /> I (�7.5v E M"iy IF.(, /Z, cf y I Sr,'" C � P�!J � - CENSUS�RA _ell, <br /> JOB ADDRESS/LOCA ION SE ,g=7-o �u1 <br /> Owner's Name SEG G"�--- ✓ � <br /> Address 3 S& E Li+�E City $T� TD�! <br /> Contractor's Name AI E/(, T121 License #-3370f'ZPhone 7512-137 J <br /> fid/ <br /> TYPE OF WORK (Check) : NEW WELL Y/ DEEPEN / / RECONDITION /_7 DESTRUCTION J-7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1. de PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT = OTHER ------ !U <br /> PROPERTY LINE A�FRIVATE DOMESTIC WELL 4rzZ2 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial L(_ Cable Tool Dia, of Well Excavation :5z, <br /> X Domestic/private Drilled Dia, of Well Casing /2- <br /> Domestic/public <br /> Domestic/public Driven Gauge of. Casing /O T , <br /> _X Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout SZg� "eV- <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: fi / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate pith 00 <br /> _ Describe Material and Procedure <br /> r <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 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 OUTING AND A YIN ,L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Ir <br /> PHASE I <br /> APPLICATION ACCEPTED BY �2 DATE --] <br /> ADDITIONAL COMMENTS: AV z <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE DATE 7 • � !�' <br /> E H 1426 Rev. - I-74 2M <br />