Laserfiche WebLink
VSANJOA9UIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,A Telephone: (209) 466--6781 <br /> .. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J7 -2we le).�� _ <br /> .� THIS PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED Date Issued a3_7 <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 /> JOB ADDRESS/LOCATION Fd,,A,)cd C&t. f P PfP CENSUS TRACT <br /> Owner's Name �y /1 .f .1 Phone <br /> E 1 <br /> Address .2 6. 1-7 eyd PH yC9 City r <br /> Contractor's Name _A4 License # e Phone <br /> i! <br /> TYPE OF WORK (Check) : NEW WE LL _ RECONDITION S <br /> / N_/ / N /� DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-7 s <br /> t. Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK 12,6r` SEWER LINES PIT PRIVY <br /> Y SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PET OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL L G PUBLIC DOMESTIC WELL f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of Well Excavation_LZ <br /> Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 7e-Al <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 /> PL42 .REPAIR: State Work Done C <br /> DES-TRUCTION OF WELL: Well Diameter _ Approximate Depth c� <br /> -Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> F apd 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 .Realth District <br /> WELL DRILLERS REPORT of the- well and notify them before putting the..well in use. The above <br /> Luformation is true to the best of my knowledge and belief. _ I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING OD A FINAL INSPECTIdN. s <br /> SIGNED <br /> iy TITLE <br /> DRAW -OT PLAN- ON RE FRSE SIDE) :, <br /> -- <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY s,' �. M a r DAT <br /> ADDITIONAL .COMMENTS: ti� <br /> .`= <br /> PYALE. I ROu INSPECTION s PMUD I-IT/IFIPAL INSPECTI N <br /> INSPECTION BY r` DATE INSPECTION BY DATE (p <br /> E H 1426 Rev.A '1-74 ,. ` 3/76 2M <br />