Laserfiche WebLink
�ell <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08,OFFICE USE:--'-- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TZ- =? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-T--,---/72> <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 Rul s and Regulations Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / `7�< ' c-C C/� C/ � _ CENSUS TRACT <br /> Owner's Name ---/�- T'e Phone- <br /> � � - 1 n1 <br /> Address �� tl� City le) <br /> Contractor's Name PX� -1- �t%°�/ --�'� License #� �'�323 Ph.zfzf <br /> meaanmam>:os®mmssmmmsmmmmmm� <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION L-7—PUMP REPAIR /-7—PUMP REPLACEMENT 2z, <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY, �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 <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: cam" <br /> PUMP INSTALLATION: Contractor *.0 <br /> Type of Pump H.P. �a <br /> PUMP REPLACEMENT: =r' State Work Done✓ `�`x -3� c ',x c ( -� t � .G��� a .. <br /> PUMP :REPAIR: /!7 State Work Done <br /> ,DES-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 District s <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE - .��&A <br /> PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II R C ON PHAS II FI AL INSPECTION <br /> INSPECTION BY A E INSPECTION BY,f' TE z f <br /> E H 1426 Rev. 1-74 1-74 2M <br />