Laserfiche WebLink
}>SAN J'OAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: J 6�,1 E.' Hazelton Ave. , Stockton, Calif. 7 ; <br /> Telephone: (209) 466-6781 <br /> A &TIOROR WILL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> _ I P�EE�MIT ,,4XPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> SAN <br /> �I�` k- �` �'omplete In Triplicate) <br /> Application is hereby '1 ��'� VU'n�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 /> A <br /> JOB ADDRESS/LOCATION �.3.�,�, 4 � CENSUS TRACT <br /> Owner's Name PhoneV 7 I'd�` J S , <br /> Address 1 City <br /> Contractor's Name License # Phone bb <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN '/ / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR'/// PUMP REPLAcEmE4T F7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <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 y <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By. } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /77--'s,tate work Done 6�, ILI <br /> PUMP REPAIR: - /State Work-. Done - ` <br /> DESTRUCTION DF WELL: Well Diameter Approximate Depth "^ <br /> Describe Material and Procedure <br /> .k <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 ISYS: <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 use. The above <br /> information is- true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIF]O. <br /> PRIOR TO GROUTING AND .A FINAL INSPECTION. <br /> SIGNED 1 TITLE 7717 0_111_� <br /> :1(Dr&WP= PLAN ON RSE SIDE) <br /> DEPART NT USE ONLY <br /> PHASE I hh <br /> APPLICATION ACCEP E D Kq V F DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE I FINAL INSPZWONf <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> 3/76 2K4 <br /> E H 1426 Rev, 1 74 _ + <br />