Laserfiche WebLink
- <br /> /' SAN JOA UIN LOCAL HEALTH DISTRICT � <br /> C�irE.MICE <br /> � � <br /> �_F 8F ICE USE: 1601 E. HazeltonrAve. , Stockton, Calif. , <br /> - Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE' ISSUED Date Issued4�7f <br /> (Complete In Triplicate) . ( P3- <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 Josquin:I <br /> County Ordinance No. 1862 and; the Rules and Regulations of the San Joaquin Local Health District. <br /> .JOB ADDRESS/LOCATION 1Low�r. =Q s rent � '9� 1�..lu ' V.kT.�CENSUS TRACT <br /> L � <br /> Owner e s Name lJ -fi i� �,/ - - __ Phone <br /> Address 7 . City <br /> Contractor's Name — License # /93 LE-Phone <br /> TYPE OF WORK (Check): NEW WELL I=T DEEPEN /� RECONDITION 17 DESTRUCTION f7 W <br /> l PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? d <br /> Other / / 0 <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 ` <br /> I Cable Tool Dia. of Excavation <br /> x <br /> l0- K Domestic/private I Drilled n Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> i Irrigation I i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection rI Rotary Type of Grout' <br /> Disposal Other Other Information <br /> Geophysical } Surface Seal. Installed By: <br /> �y <br /> 1E �utraa��-Isn±,,.�f U�•me�v+.7 ua.�-. � <br /> PUMA' INSTALLATION': Contractor � <br /> Type"of Pump a H.P. <br /> y <br /> PUMP REPLACEMENT: / / State Work'Done <br /> _PUMP '.REPAIR: / State Work Done Jagap 11/0 044 <br /> A roximate Depth <br /> 2LE ,TRUCTION OF WELL: Well. Diameter PP <br /> - Descibe' Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4 and the State of California pertaining to or regulating well construction. Within 'FIFTEEN DAYS <br /> after completion of my worklon 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 tsse.. The above <br /> information is true to the best of my . n wle a and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR T UTING AND A FINAL i * <br /> I SIGNE TITLE <br /> DRAW PLOT PLAN 0 VERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> h ADDITIONAL COMMENTS: I <br /> PHASE II GROUT; INSPECTIQN PHASE III INAL INSPEC ION <br /> 1-2 <br /> INSPECTION BY ;i, DATE INSPECTION BYi _ D E <br /> `t E H 1426 Rev. 1-74L% 1-74 2M- <br />