Laserfiche WebLink
fT SAN JO QUIN LOCAL HEALTH DISTRICT <br /> �_. Ln� <br /> I OE OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -' Teleahoue: (209) 466•-6781. <br /> AYPLICATIOIT FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _3tl- <br /> (Complete In Triplicate) <br /> I plication 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 /> unty Ordinance No. 1862 and the Rules and Regulations of the San' Joaquin Local Health District. <br /> r f CENSUS TRACT <br /> S-B ADDRESS/LOCATION f l <br /> C-ner's Name" Bre / •"7 Phone <br /> Address `7 �r�/ ate.// V _1LCity <br /> ntractor's Name cc � License <br /> ISTY- <br /> E i <br /> PE OF WORK (Check) : NEW WELL '/X DEEPEN / / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION 'Z/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> E other <br /> STANCE TO NEAREST: SEPfiIC TANK/'�D SEWER LINES PTT PRIG'Y � � <br /> SEWAGE DISP SD AL FIELD CESSPQOL/SEEPAGE PIT / OTHER <br /> �' PROPERTY LINE��PRIVATE" DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> � � INTENDED 'USE TYPE OF WELZ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> n Y. Domestic/private Drilled Dia: of Well Casing (a <br /> { Domestic/public Driven Gauge of Casing C <br /> ra�re� l'ac�c-- -- De t � Groin-52a� <br /> Cathodic Protection Rotary ` Type of Grout <br /> [—Disposal Other Other information <br /> Geophysical . Surface Seal Installed B : <br /> F2T INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> 'TMP <br /> REPLACEMENT: . /_/ State Work Done \/ <br /> PUMP .REPAIR: / / State Work Done V <br /> i .S-TRUCTION OF WELL: , Well Diameter Approximate Depth <br /> Describe- Material and Procedure <br /> Fhereb :ag ree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Y <br /> -'id 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 /> FLL DRILLERS REPORT the well and notify them before putting. the..well in use. The above <br /> aformation is tr o e est.-.e-�my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND A F AL NSP 17 <br /> YGNED TITLE <br /> DRAW Pt OT' PLAN"ON REVERSE SIDE) <br /> OR.DEP MENT USE ONLY <br /> I �� <br /> rSE <br /> LICATION ACCEPT Y DATE -3p <br /> nDDITIONAL COMMENTS:, <br /> PHASE II 'GROUT'INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BYDATE Q 7 INSPECTION Bt�QDATE <br /> 3/76 2M <br />