Laserfiche WebLink
V/ <br /> SAN JOAQUIN LpgAL_ HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton� ve. , ,Stockton, Calif. <br /> 41 Telephone: (209) 466-6781 <br /> ANOLI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _c (/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- "�/ '70 <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 ,1l t/7,a �, 6-S,tda y CENSUS TRACT <br /> Owner's Name tr2SPhone 7/,3 <br /> Address 2 / .S"Z.4,Z I Z`,C 1.r.�.d V City E ati <br /> Contractor's Name ,,��� License #� s� U Phone � = <br /> --- 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rOQ PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT —_ OTHER <br /> PROPERTY LINE 4 *RIVATE DOMESTIC WELL-V±* PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ., C' <br /> Industrial Cable Tool Dia. of Well Excavation 4,0 <br /> Domestic/private Drilled Dia. of Well Casing 4.9 <br /> 01 <br /> Domestic/public Driven Gauge of Casing 0_0. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information /,f t,$ <br /> Geophysical Surface Seal Installed B <br /> Ao />,P "T' /°%3457 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DES®RUCTION 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 _ nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR NG D A F AL S <br /> SIGNED TITLE <br /> Ll (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 07_� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PMSj I /FINAL INSPECTION <br /> INSPECTION BY DATE _ N INSPECTION B DATE. - Oi-/$ <br /> E H 1426 Rev. 1-74 <br /> 1/77 " 2M <br />