Laserfiche WebLink
r� '�"-' `e 4-o Cs SAN JOAQUIN LOCAL HEALTH DISTRICT - (- <br /> FOPSTOFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> rt' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /?-5-- S6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) (g3 6S0--a.6 <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 Ar,,L C>&/_ g2 0.1�2 CENSUS TRACT <br /> I <br /> Owner's Name onA d.-a Phone <br /> Address 1 W .r ap s4!!� city <br /> T <br /> Contractor's Name ` ,t License # 1,4 � phone <br /> F <br /> i <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN -/? RECONDITION /-7 DESTRUCTION / a <br /> PUMP INSTALLATION / / PUMP REPAIR jL(-/ PUMP REPLACEMENT <br /> Other <br /> Other % / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, 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 Casingi <br /> Domestic/public Driven Gauge of• Casing <br /> r 1 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: Vit ; <br /> PUMP INSTALLATION: Contractorza <br /> , '. <br /> Type of Pump rl,• H.P. / 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'.REPAIR: /1C/ State Work Done o <br /> ES,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 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 TOG UTING AND A FINAL-JNSPECTIOKj <br /> SIGNED ►..CE `'-" � �.�w _ TITLE A <br /> Ov g=MW PLOT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II11FINAC INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Ste- `" 2,I <br />�01E H 1426 Rev. 1-74 1-74 Im <br />