Laserfiche WebLink
SAN 30AQUIN LOCAL HEALTH DiSTRICT <br /> F0TZFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif.: t <br /> Telephone: .. (209) 466-6781 <br /> 'i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .I (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 CENSUS TRACT <br /> Owner s Naiinek - Phone '�C� �()Q 7 <br /> Address - .75/z y City <br /> f Contractor'-s Name;:LjA T� �1 �/��� . ,.._C_O. License # - GG.GZ Phone <br /> TYPE,OF-WORK-(Check.): -NEWWELL--/)�'—DEEPEN--/""RECONDITION/_�DESTRUCTION"f7'' <br /> rPUMP INSTALLATION / /. PUMP REPAIR /� PUMP REPLACEMENT <br /> Other / <br /> k i <br /> DISTANCE TO NEAREST: , SEPTIC TANK ;W-0 -+,SEWERLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' e PROPERTY LINE PRIVATE DOMEST.IC'LWELL PUBLIC DOMESTIC WELL <br /> INTENDED USE JTYPE OF WELL;, Tart ;CONSTRUCTION SPECIFICATIONS <br /> ? Industrial c ti X Cable Tool `Dia. of Well Excavation f <br /> Domestic/private %4 . Drilled 619:—. of Well Casing <br /> ' Domestic/public Driven ', Gauge of Casing <br /> Irrigation / n\ GraveVack Depth of Grout Seal ' <br /> �. Cathodic Protection A'�j 1 Y Rotary "' 4. r Type of Grout <br /> i Disposal 'i Other Other InformationE <br /> Geophysicals 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ +' H.P. <br /> ` 1 <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> a \� <br /> PUMP'-REPAIR: /71 State Work Done ,. <br /> Ih &ES-TRUCTION}OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> t agree to comply with all laws and-regulations of the San Joaquin Local Health District <br /> I hereby agr p y $ <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 furnishthe San Joaquin Local Health District a <br /> ry WELL DRILLERS REPORT of the well and notify them before putting the..well in use.. The above <br /> informati s to e, st of my-knowledge and belief. I' WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO INA D A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT -PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ;DATE � 44D4 96 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION ;BY DATE INSPECTION BY "L DATE - "7�� <br /> � : E H 1426 Rev. 1-74 1-74 ZM <br />