Laserfiche WebLink
F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT`S ; <br /> FOBiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z-z,,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date. Issued /1 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9a ' %V21 CENSUS TRACT <br /> Owner's Name !hens <br /> Q <br /> Address _ 1,23 ��. 64g o -Tom . � �L city <br /> Contractor t.s Name JA��72�& A-)0t5G11r License # 7� Phone - gf7 <br /> TYPE OF WORK (Check): NEW WELL ,& DEEPEN '/-7 RECONDITIONIT DESTRUCTION /7 <br /> PUMP .INSTALLATION "/ / PUMP REPAIR -/-7—pump REPLACEMENT <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 -Wel-1 Excavation yAj Ale <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / 4<- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X . Rotary Type of Grout.`_ _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> J_ 4T <br /> PUN P REPLACEMENT: . State Work Done =W <br /> PUMP '.REPAIR: / // State Work Done <br /> ,PES•TRUCTION 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 .n.ife.... .The above <br />'. information is true to the-best-of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />; PRIOR TO GRMIN9 'AND A FINAL INSPE060N. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HA$E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY dZ291,7 DATE <br /> E H 1426 Rev. ;1-74 r. r' 4/75 2M. <br />