Laserfiche WebLink
SAN JCMU:IN LOCAL HEALTH DISTRICT - <br /> I FOR+!OFFICE DISE: l/ 1601 E. Hazelton Ave. , <br /> Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6-�9�rin <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7� <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 �O CENSUS TRACT <br /> su a <br /> Owner's Name Phone ',---740 <br /> Address r <br /> City elei <br /> Contractor's Name _ isceiZ ._ .W_ License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN/_7 RECONDITION /7 DESTRUCTION /7PUMP INSTALLATION ) PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELT.: PUBLIC DOMESTIC WELLp <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 /> I 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: <br /> E I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P: AlY _ - <br /> PUMP REPLACEMENT: '/ / State Work Doneant <br /> l <br /> f PtM wREPAIR: /? State Work Done _ <br /> ESIRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> e <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.Fthe 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.'FI <br /> NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y, DATE <br /> ADDITIONAL COMMENTS: /12 dffl AA U <br /> PHASE RO SP C ON S II NAL INSPECTION <br /> INSPECTION BY "-- DATE SPECTION Y DATE .f:3 76 <br /> a,. a ew kral rar -E, <br /> E H 1426 Rev. 1-74:; yf- �7�•' �, c /�il� 1-74 2M <br /> t : <br />