Laserfiche WebLink
} <br /> r/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE -USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466- 67$1,,- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ_I;U,A,&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance With San Joaquin � <br /> County Ordinance No. 1862 and the- Rules and Regulations of the San'-Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCA �3 CENSUS TRACT <br /> r� <br /> Owner's Name Phone / f <br /> Address `�- Cit <br /> + Li se AJC-''2�� Shone <br /> Contractors Name --- ! <br /> TYPE OF 'WORK (Chedk) -NEW-WELT: jy`-_DEEPEN- /_.-/-=riRECOND-1TION/,L-744 DESTRUCTION-/��._- <br /> PUMP INSTALLATION PUMP REPAIR I PumP REPLACEMENT 17 <br /> �4ther,* / <br /> — - <br /> DISTANCE ZOXEAREST: SEPTIC TANK SEWER LINESV PIT PRIVY <br /> SEWAGE DISPOSAL YIELD. CESSPOOL/$EE$AGE PIT OTHER <br /> AD-PROPERTY LINE 'PRIMATE DOMESTIC WELL PUBLIC DOMESTIC 6dE L <br /> INTENDED USE -,e_TYPE_ `OF.'WELL _ CONSTRUCTION SPECIFICATION <br /> Industrial; .. (Cable Tool Dia. of Well. Excavation <br /> L,---Domestic/private :' # �` ' ,Drilled Dia. of Well Casing r . <br /> Domestic/public 4'a' Driven ' Gauge of Casing <br /> Irrigation, f '` Gravel Pack Depth of Grout Seal <br /> Cathodic <br /> Protection f•, RotaryType o <br /> f Grout _ <br /> �, . .� � � <br /> Disposal n Other �` Other Information <br /> Geophysicalace Seal I stalled B <br /> - n <br /> # <br /> PUMP- INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENf: /�,/ ' 'State Work Done. <br /> PUMP .REPAIR: ,- "./ State;Work Done <br /> DES-TRUCTION`"OF WELL: We-1-1-y-DLame terr Ap.proximate_;-Depth <br /> Describe Material and Procedure <br /> ' I hereby agree to comply with_.a11•,laws. .and,,regulations of the San Joaquin Local Health District <br /> and the State.. of California pertaining-„,tio or regulating well'-construction. Within FIMIN DAAS_ <br /> after completion of.,.my work-on a new well, 1 will furnish the San Joaquin Local Health District .a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 /> SIGNEDTITLE <br /> PW <br /> TIW':P PI 'ON SE SIDE j <br />' FOR DEPARTMENT USE ONLY �. <br /> PHASE I <br /> APPLICATION ACCEPTED $Y'► DATE • -7'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSPECTION <br /> P SE III FINAL INSPECTION` <br /> INSPECTION BY -+' DATE Z 7 INSPECTION BY DATE -. <br /> V7.6 ' <br /> L H 1426 Rev. 1-74 <br />