Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na, 7� �`� <br /> ` ��S� <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date issued l6-6 74 <br /> (Complete In Triplicate) ; <br /> Application is hereby made to `the SrnibedJoaquin <br /> ThisLocal <br /> application isDistrict <br /> made infor <br /> complianceto construct <br /> with San Joaquin ! <br /> and/or install the work herein desc qV-f <br /> ocal Health Distr ct. <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Jaa vagZ� z (20 <br /> CENSUS TRACT ' + <br /> JOB ADDRESS/LOCATIONt" <br /> Phone <br /> Owner's Name <br /> ..�.. .. City;. ;. •.; ; <br /> Address ' <br /> License-Iff _J�Phone <br />-Gontrac t•or'.s�„Name ' <br /> �DE`EPEN''/ �v RECONDITION'`/ I 'MESTRUCTION /_7 <br /> TYPE OF WORK (Ch k).:,,. NEW WELL /!'] PAIR / PUMP RFI!-- CEMENT /_7 <br /> `PUMP�INSTALLATION / UMP RE /_ i <br /> 'O.the`rf.:.77 <br /> ' <br /> f IT PRIVY <br /> .s WER.LII�ES , <br /> I' .DISTANCE TO NEAREST: SEPTIC �'L°ANK / <br /> SEWAGE�DISP AL FIELD -f ESSP00L/SEEPAC=E PIT�OTHER• <br /> PROPERTY LINE = PRIVATE DOMESIC'WELL: PUBLIC DOMESTIC WELL <br /> ' . � CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF:.WELL. 01 <br /> r� <br /> t Cable Tool Dia./of Well•'Excavation, <br /> In strial. �' •-.�' h <br /> Domestic/private `'-ry '-'Drilled Dina. of Well' Casing <br /> Gauge of Casing <br /> Domestic/public e` Driven g *_ �. <br /> ' • •'”" Gravel Pack /Depth of Grout Se <br /> Irrigation <br /> �� ,,,, _ype of Grout <br /> -Cathodic 'Pc " <br /> rotection` �tary , <br /> - _ =Other _# Other Information° ' <br /> Disposal'=` _ # Su.s Seal Installed B <br /> ' .'Geophysical <br /> -'PUMP"INSTAT;ATII t <br /> ON. - ContrC'tot .� - P. <br /> •ft"1V" f i <br /> F - Type of Pu ,. <br /> PUMP REPLACEMENT: / /'.. State Work Done .`f <br /> - r rk ,Done <br /> R PUMP .REPAIR: State Wo <br /> Y:�. , <br /> Approximate I Depth <br /> DESTRUCTION OF WELD: Well Diameter: r <br /> Desoribe', Mater ial and Procedure <br /> t�i DistrictI hereby agree to c' mply vFith all laws and regululatin ations owellecanstrucSala t3on.LoWith naFIFTEEN DAYS <br /> and the State' o€. California�gertaining to or reg �.^ g <br /> after completion ofFmy'o!rk-o a d not �themW,illbeforef urn sputtingh the athe��we11 inaquin ouse. Thehaboverlct a <br /> WELT, DRILLERS REPORT of the well a Y <br /> inform is true t b d,4f .my. knowledge and belief. I WILL .CLLL FOR A GROUT INSPECTION <br /> 'PRIOR TO NG AND FIN <br /> TITLES) <br /> SIGDRAW 'I: T' PLAN ON RE FRSE.SIDE) , _ l <br /> FOR DEPARTMENT USE ONLY <br /> EPHASE=I 3 - DATE - ' <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS ,�^ PHAS . I/ INSPECTIO <br /> P II OUT INSPECTI <br /> INSPECTION: (/B DATE •� —.—INSPECTION BY / � DATE <br /> 3/76 2M <br /> 1-74 <br /> E H 1426 Rev. f.:...,,.'• <br />