Laserfiche WebLink
V/ <br /> SAN JOAQUIN OCAL HEALTH DISTRICT <br /> 0— rOF^ CE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATIONS FOR WELL CONSTRUCTION OR PUMP PERMIT Permit.No. 7s=331�v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued5�� <br /> (Complete In Triplicate) IP3- - 04,0 !�`•. <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 <br /> 'Ordinance N0.• 1862 and� the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION r {� CENSUS TRACT <br /> Owner-'s Name Phone f'.. <br /> Address ": - City <br /> Contractors Name s License # 4_q Phone <br /> f <br /> i a� <br /> TXPE_OF WORK-(Check.)_:,;_NRW� W£rLI.Y-� DEEPEN / "rRECO DITIUN / DESTRUCTION <br /> PUMP INST CATION /% PUMP REPAIR /%_ PUMPREPLACEMENT 1 Ln <br /> r Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES E PIT PRIVY ., ^. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS 1 OTHER <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE " 'TYPE OF -WELL 3 CONSTRUCTION_SPECIFICATIONS <br /> -' Industrial "- .� .. �a Cable Toa1 `�._ _ .Dia.,of�--Welly-Excava-t4�n � <br /> Domestic private 11 Drilled Lr_------Dia.-of!,Well Casing-:2-y <br /> Domestic/public DrivenF Gauge of Casing 1'Jyofz <br /> f —Irrigation Oravel PAck Depth of Grout Seal i <br /> Cathodic Protection-- Rotary Type of Grout <br /> Disposal 14_j,. Other s ' Other Information i f <br /> Geoihysical /''f{ ;, 'Surface Seal Installed By,:. <br /> PUMP INSTALLATION: Contractor <br /> N. Type of Pump A.P. <br /> PUMP REPLACEMENT: / / S tate'Wdik Done * <br /> PUMP :REPAIR: w-7 state'Work Done <br /> x <br /> ES TRUCTION-OF WELI;: s We :i"D3a a to Approximate Depth <br /> Describe Material'-and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DisjDAYS <br /> and the State of Californie-pertaining-t-0 or regulating well construction. Within FIFTEENafter completion of my work on a new well., I will furnish the San Joaquin Local Health DisWELL DRILLERS REPORT of the well and notify therm before puttingthe well in-use.. The abovinformation is true to the best of my -knowledge and belief. -I 'WILL--M1rFCR A GROUT INSPEC <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - - - - - <br /> PHASE I <br /> APPLICATION ACCEPTED -BY-� -w r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION _ PHASE II FINAL INSPECTION <br /> INSPECTION BY `DATE g 7 6- ;_7 INSPECTION BY / DATE 2 C <br /> �;� E 11 1426 Revs 1-74 v 1-74 2M <br />