Laserfiche WebLink
i <br /> Ldp Is E � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICEUSEF: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> ��. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _5--Z2-2 <br /> ,7 <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /# 0-1, S �� ,, CENSUS TRACT <br /> Owner's Name s ` Phone <br /> Address �;�!0 3� I�io'�_ City <br /> Nal <br /> Contractor's Naive , License # 19.L?-Th-ne Wil- -71C 7.6 F <br /> jN <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/�/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTLATION/ / PUMP REPAIR;. PUMP._REPLACEMEN.T., / <br /> AL , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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 Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> (� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout R <br /> —Disposal � Other Other Information ' <br /> Geophysical, Surface Seal Installed By: _ , <br /> A, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 440 <br /> PUMP REPLACEMENT:- -' ' State Work Done r` <br /> (" E <br /> PUMP °.REPAIR: _Lel State Work Done � �7 4aa�t .•- ,�. _ <br /> DESTRUCTION 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 futnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use. The above <br /> information is true to the best of my kn wle ge a d belief. . I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR .TO GROUT G AND A FI AL INSPE <br /> SIGNED E <br /> I) {DRAW 0 PLAN ON REVE IDE) "r <br /> 0 EPARTMENT USE ONLY <br /> PHASE I �, <br /> APPLICATION ACCEPTED BY DATE &-7 7 <br /> ADDITIONAL COMMENTS: (/ <br /> PHASE I ' GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY JW DATE INSPECTION BY DATE <br /> E_.H-.j1426 Rev. 1-74 - -- f I7 2M <br /> - <br />