Laserfiche WebLink
I <br /> 1 <br /> SAN !LAQUIN LOCAL HEALTH DISTRICT . . <br /> OFF= USE: 1601 S. Hazelton a✓e. , Stockton, Calif. <br /> Telephone: (209) 406-6781 �yy� <br /> APPLICATION FOR WELI. CONSTRUCTION OR PUMP PERMIT Permit Nu. �j-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ! J <br /> (Complete In Tri-plicate) <br /> lication is hereby made to the San Joaquin Local Health District for a pe-mit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaquin <br /> my Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> ADDRESS/LOCATIONAar- IN CENSUS T-R.ApCT <br /> trl <br /> er's Nr<< (]�[' �" �r-� -� Phone% L- <br /> i <br /> ressQ3q I / Ino 'ArT12G yC LZ, CityeetL1f� <br /> tractor s Name <br /> e L C tE�'L I y Licen,e f� phone <br /> Qlvr') t.t.) <br /> i <br /> E OF WORK (Check) : NEW WELL /-7 DEEPEN -7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / 7 PUMP REPLACEMENT /7 <br /> Other / / 7- <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL t <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 /> Irridition Gravel Pack Depth of Grout Seal # <br /> Cathodic Protection Rotary Type'of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed B <br /> T INSTALLATION: Contractor l j'rL.S/' L/MP lr-.�p El <br /> Type of Pump <br /> IP REPLACEMENT: ( / State Work Done ' <br /> 1P REPAIR: / / State Woik Done <br /> TRUCTION OF WELL: Well Diameter , Approximate Depth <br /> Describe Material and Procedure — <br /> :ereby agree to comply with all laws and regulations of the San Joaquin Local Health District ' <br /> I the State of California pert-i^tng to or regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work o,- a new well, I will furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formatio is true to the bes ofy knowledge and belief. I WILL CA1 OR A GROUT INSPE1CTION <br /> UR TO }ITING j+ND A FIN L qSY CCION. <br /> LE <br /> GNt'D (DRAW PLUT PLAID ON REVERSESID <br /> f� — <br /> FOR MENT U E C Y ` v <br /> ASE I L01 T <br /> DATE <br /> PLICATION ACCEPTED L' <br /> DITIONAL COMMENTS: n ` PHASE I FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> SPECTION BY DATE INSPECTION By D/ <br /> 6/77 2M <br /> F. 11 1426 Rev. .1-74 <br />