Laserfiche WebLink
I! SAN JOAQIJIN LOCAL HEALTH DISTRICT <br /> FOBeWFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,:�4 t <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local. Health. District -fora permit to construct .... ] <br /> ,and install the work herein described. This application is made inJcompl.iance with' San 'Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of- the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j „ . O LT ED- CENSUS-TRACT <br /> Owner's Name tyl C H 19 R D r___F_7_ Phone 75 - 26S/6 <br /> 17 <br /> Address >/� V� r �C CPI-L City. r� <br /> Contractor's,Name Q W rV5 jZ. License Phone y <br /> TYPE,OF-WORK' (Check) : NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION <br /> F PUMP INSTALLATION /N —PUMP REPAIR / / PUMP REPLACEMENT <br /> ++ Other <br /> DISTANCE TO NEAREST; SEPTIC TANK j,�o SEWER LINES /SU PIT PRIVY IVONr <br /> SEWAGE DISPOSAL FIELD CESSPOOL%EPAGE PIT !! ONS OTHERvf <br /> PROPERTY LINE30 PRIVATE DOMESTIC WELL��N� PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Did. -.of Well Excavation <br /> Domestic/private Drilled Dia. of Weli Casing <br /> _„�Doiaesti�r,�puh�:fic Driven=� =�-�"�Gauge�ofYCasi.ng� N �-^ -► �- - ESO <br /> Irrigation Gravel Pack -! Depth of Grout Sea] p <br /> Cathodic Protection Rotary Type of GroutCIE M F <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 8 : iOVNs <br /> PUMP, INSTALLATION: Contractor OW AlF—F,' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /_7 State 'Work Done` <br /> DESTRUCTION OF„WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a :� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin- Local Health District � <br /> afid 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 DRILLER REPORT of the well and notify them before putting.. the..well in-use.. The above f <br /> informat true,;o the b t of my-knowledge and belief. I WILL XALL" FOR A GROUT INSPECTION <br /> PRIOR UT G P ION. <br /> SIGNE TITLE. I <br /> DRAW PLOT PLAN ON REVERSE SIDE5 , <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE ATE <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION / P IMAL INSPECTION <br /> INSPECTION BY DATE �`�d`�� INSPECT DATE — f <br /> Ou'F— -T Af STA LIED a DID W 0-v- <br /> 4 fj <br /> E H 1426 Rev. 1-74 611-L FDF1 IN5T •-t,R r>_; 7 Im �. i <br />