Laserfiche WebLink
r . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> % Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Jd-/6,P V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 41vE-il (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 f the San 'Joaquin Local Health District. <br /> wcticl" q JOB ADDRESS/LOCATION U - YY? r 1\I CENSUS TRACT <br /> Owner's Name I f t/ --S Phone ZZ ;12/ 7Q <br /> Address -s-e City 2,�Z7- ,,Oryp <br /> Contractor's Name License #,2,0,5_5/phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/-7 RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION 0 PUMP REPAIR /_7 PUMP REPLACEMENT /_7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY �-- <br /> SEWAGE DISP SO AL FIELD CEMPOOL/SEEPAGE PIT OTHER <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 /S <br /> ,X 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 "V <br /> -- ja� <br /> u a <br /> Disposal Other Other Information�r <br /> Geophysical Surface Seal Installed By: Y/o,c,2 -. WFJI <br /> PUMP INSTALLATION:. - Contractor <br /> Type of Pump L H.P. 7 = <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> DESTRUCTION 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... a above <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FO A:GROIjf INSPECTT N <br /> PRIOR TO GROUTING A PIN INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: / <br /> PgA&o I R _ INSPECTION PRM, ITA'OFINa INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE A/K <br /> fj <br /> E R 1426 Rev. 1-74 __._h/75 2M <br />