Laserfiche WebLink
FOR OFFICE 5 •r SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. - { <br /> r Telephone . _ 1 <br /> APPLICATION FOR WELL CONSTRUCTION 6ORPUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,ApplicationI (Complete In Triplicate) Date Issued <br /> is here2 b made tthe San Joaquin Local Health District for a <br /> &_2!Z_2and/ox install the work herei7 <br /> n described. This applicationconstruct <br /> County Ordinance No. 1862 and the Rules and Regulationsofthe Sanis eJoa Joain quin <br /> Local He with Di tr <br /> � aqu3.n <br /> ,�. q in Local Health District. <br /> JOB ADDRESS/LOCATION - <br /> S ENSUS TRACT <br /> Owner's Name c- / /�� MO/P <br />! Address r <br /> Phone <br /> k �-• �, `yG�ty ,. <br /> Contra[tor s Name ��v ��� <br /> r✓�._S'?' Gv pa.D License h�e �7 <br /> -7 <br /> 832! <br /> TYPE OF WORK (Check) : ,:NEW WELL / DEEPEN4 <br /> RECONDITION / / DESTRUCTION /� <br /> PUMP INS AL ATION PUMP '.REPAIR ` <br /> • Other / / Pte' REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TAN <br /> SEWER LINES . PTT PRIVY O <br /> SEWAGE DISPOSAL FIELD <br /> CESPROPERTY LINE - PRIVATE DOMESTIC SWELL PUBLIC/SEEPAPIT OTHER <br /> INTENDED USE TYPE OF WELLDOMESTIC WELL <br />�� .Industrial CONSTRUCTION SPECIFICATIONS L\ <br /> _ <br /> Domestic/private Cable Tool ,- Di , well Excavation <br /> /Private #. Drilled aof WDia, of Well Casing /� f <br /> Domestic/public t^ Driven <br /> Irrigation , ;gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal f <br /> I _ Rotary Type of Grout -- cl <br /> Disposal t Other S"�J <br /> Geophysical t Other Information <br /> Surface Seal Installed B <br />?UMP INSTALLATION: - <br /> Cont " " ' <br /> ractor / 'S-D/�/ <br /> Type of '-Pump Z. <br /> t -� H.P. <br />'IP REPLACEMENT. Z 7 6/ State Work Done • � � <br /> UMP -REPAIR: <br /> State Work Done �7 '�3 s -�•- - <br /> ESTRUCTION OF WELLv� ill, PIC <br /> rn <br /> Well Diameter s <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well cans r <br /> Eter completion of my work on a new well, I will furnish the SantJoaquin.LocalhHealthin Tis DAYS <br /> ELL DRILLERS REPORT of the well and notify them_'be'fore putting the..well in use.. The above i <br /> District `a <br /> iformation is true�.to the-best 'Of- my..knowle.dge_and-belief_.—I -WILL -CALL-.FOR .A GROUT INSPECTIO <br />,DOR T ROUTIN AND A NAL INSPECTION. <br /> CGNED <br /> TITLE iLI E <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br />[ASE T <br /> FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTE <br /> iDITIONAL COMMEN DATE' r-7? <br /> PHA II GROUT INSPECTION PHASE INAL NSPECTION <br /> SPECTION BY DATED p INSPECTION BY TE ' <br /> E. H 1426 Rev. 1-74 l _ X <br />