Laserfiche WebLink
F` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Aver, Stockton, Calif. <br /> Telephone: (209) .466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. �7�191•J <br /> THIS PERMIT EXPIRES .I YEAR -FROM DATE ISSUED Date Issued _/3-7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> axed/or install the work herein described. _ This application is made in compliance with San Joaquin- <br /> County Ordinance No. 1862 and the Rules znd Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION Z690 CENSUS TRACT <br /> Owneir°s Name /it/,/�rte-, .� . Phone <br /> Address City <br /> Contractor's Name License 44,00�7y Phone <br /> f <br /> TYPE OF WORK (Check): NEW WELL J�T DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIE6i CESSPOOL/SEEPAGE PIT OTHER <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing-1 j.2- <br /> Irrigation Gravel Pack Depth of Grout Seal o <br /> Cathodic Protection. Rotary , Type of Grout <br /> Disposal. � Other # � Other Information ; <br /> Geophysical Surface Seal Installed By: C, - <br /> PUMP INSTALLATION: Contractor 3 o-�G 1G <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ' PUMP `.REPAIR: /-TState Worts Dane a <br /> UES4RUCTION 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 District a <br /> WELL DRILLERS REPORT of t ell and notify them before putting. the-well in.use.. The above <br /> information is true t e•b t of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI - I <br /> SIGNED ti TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR=DEPARTMENT_USE.ONLY l <br /> PHASE I <br /> APPLICATION ACCEPTED BY . " "" -.ti _: DATE <br /> ADDITIONAL COMMENTS: Q. Al LIC844 Qsxk& <br /> PHASE I GROU INSRECT.ION,.-•.. _ 'P I FINAL INSPECTION f <br /> INSPECTION BY , i DATE 7 7 INSPECTION BY DATE <br /> } E H 1426 Rev. 1-74 12/0 -6a;r ✓ � 1-744 <br />