Laserfiche WebLink
'AN JOAQUIN LOCAL HEALTH DISTRI- <br /> FOA OFFICE USE: 1~� E. Hazelton Ave. , Stockton, Ca If , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]- Iq 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q-F- �7 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ;SCJn/ E, LfJ l/S,e AVE AATNRoP CENSUS TRACT <br /> Owner's Name M4AI-rFC4 �it/i/ iEn s N�n� �iST Phone 9237II1 <br /> Address P O AOX 3 2 /bl &7-; YA City AIA A/7 _CA <br /> Contractor's Name iUD,AC:K / 96o/ 7P MUG License Il;�[J079y Phone9y,Q-F?/r/ <br /> TYPE OF WORK (Check) : NEW WELL 1a..' DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 121, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /.2 r A, <br /> Irrigation _1>� Gravel Pack Depth of Grout Seal S-D <br /> ;cathodic Protection �> Rotary Type of Grout /3EN719N/TE (� <br /> isposal Other Other Information o <br /> Geophysical Surface Seal Installed By: A/OACK ,O[/iYJ <br /> PUMP INSTALLATION: Contractor /1/OAC/s All"P ANG, <br /> Type of Pump S06^EKSiD/E H.P. Z yP <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. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG D A NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> O FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY�� DATE <br /> ADDITIONAL COMMENTS: <br /> PHA , II ROUT INSPECTION PHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE - S 1:2 INSPECTION BY Cjj DATE - <br /> E H 1426 Rev. 1-74 _�i, <br />