Laserfiche WebLink
9 d _ <br /> FOR' SAN JOAQUIN LOCAL µ , <br /> ROfi:0 1I;li SE: HEALTH DISTRICT "4 f <br /> 1601 E. Hazelton Ave., Stockton, Calif: <br /> ,{- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NO?7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued i <br /> Application 'ie hereby made to the San Joaq ineLocal Homplet11n ealth District fore , <br /> and/or install the work herein described. This for is made in compliiaancetwithnaanu3oaquin} <br /> Cooney ordinance No. 1862 and the Rules and Regullations of the San Joaquin Local Health District. I <br /> JOB ADDRESS/LOCATI ONSUS TRACT <br /> G/ �QtLLXJ <br /> Owner's Name <br /> Address Phone <br /> � <br /> City.__Tdar�%fa <br /> Contractor's Nasty <br /> License Phone 7 '/ <br /> i, <br /> TYPE OF WORK (Check): NEW WELL i7y"Dggpgg /-7 RECONDITION /_f DESTRIICTION (l <br /> PUMP INSTALLATION /� PUMP REPAIR -7 PUMP REPLACEMENT /? { <br /> Other <br /> )ISTANCE TO <br /> NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD eg-L 1+ CESSPOOL/SEEPAGE PIT <br /> PROPERTYiLINE - PRIVATE DOMESTIC L.._ PUBLIC 3 ICOTHER <br /> ZNTENDHD IIS8 TYPE OP WELL <br /> _ IndustrialCONSTRUCTION SPECIFICATIONS <br /> .J/ Domestic/private Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> _ _elZomeeti�/.publie� - ea• -- <br /> Irrigation n <br /> Gravel Pack <br /> Cathodic Protection Rotary Types of Grout <br /> rout <br /> Seal i <br /> —Disposal 1 Other Type of Grout { <br /> Geophysical Other Information _ <br /> ` Surface Seal InstaIle B <br /> UMP INSTALLATION: Contractor } <br /> .. x i Type .of Pump <br /> _ <br /> T' / / State Work Done N <br /> 7MP-REPAIR t <br /> E7 .State Work Done <br /> &TRUCTION OF WELL: Well Dia ter t ~ <br /> Describe Material and.Procedure Approximate Depth <br /> hereby agree to c <br /> amply with ali lave and re ulatione of the San Joagin Local'Health District <br /> ;d the State of California pertaining to or regulating well'constructioII. Within PIFTEEN DAYS <br /> 'ter DRILLERcompletS <br /> RE of my work on a new well, I will furnish the San'Joaquin Local Health District <br /> LL DRILLERS REPORT of the well and notify them before puttingthe..well In use. The above <br /> formation is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPE <br /> IOR TOG UTING AN A AL IN SCTZO <br /> GNED <br /> TITLE <br /> D PLOT ON REVERSE SIDE <br /> ASE I DEPARTII@TT USE ONLY r <br /> 1TION ACCEPTED DY <br /> )1rzONAL CODp2NTg; DATE <br /> PHAS II �ZN' ECT � i • { <br /> iPECTIONBYP 11 <br /> DATE INSPECTION BY INTEECTION <br /> E H 1426 Rev. 1-74 <br />