Laserfiche WebLink
co 4-4 Y SAN JOAQUIN LOCAL HEALTH DISTRICT - __- <br /> FORiO FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. F <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,::C� S <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 hereiii described. This application is made in compliance with San Joaquin! <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> . -?c 4"£ - I l Z7-2-049-0?- <br /> JOB ADDRESS/LOCATION 1-- C00AW4 z&.0C9 CENSUS TRACT <br /> Owner Is Name TD�t K t 'G y� Phone � <br /> Address I i 37 City (Sad <br /> �7` <br /> Contractor's Name License `g�hone ,. 7 <br /> i <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/% RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR 5 PUMP REPLACEMENT J <br /> Other % 7 <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 c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private : Drilled Dia. of Well Casing Piz. ` <br /> Domestic/public = Driven Gauge of Casing <br /> �A, Irrigation i Gravel Pack Depth of Grout Seal t <br /> = Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information `g <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 9Z�4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / State Work Done Q - <br /> i <br /> ES•TRUCTION OF WELL: Well Diameter Approximate DepthJDAYS <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dand the State of California pertaining to or regulating well construction. Within FIFTEafter completion of my work on a new well, I will furnish the San Joaquin Local Health DWELL' DRILLERS REPORT of the well and notify them before putting the..well in-use. The ab <br /> information is true to the-best-of <br /> owl d elief. I WILL CALL FOR A GROUT INSPECTION 3 <br /> PRIOR TO U ING AND A FINAL . s <br /> SIGNED LE t <br /> PLAN ON SE SIDE— - .. <br /> k-10OR DEPARTMENT USE ONLY <br /> PHASE I --7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE T I IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> �� E H 1426 Rev. 1-74 1-74 2M <br />