Laserfiche WebLink
7g - <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , -.Stockton, Calif. <br /> R I Telephone:' (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT- EXPIRES l YEAR FROM DATE ISSUED Date Issued 1Li9 7� <br /> .(Complete In..Triplicate) <br /> Application is hereby made to the Salt Joaquin Local Health:Diattict 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 , Zl_ax:77 ( x CENSUS TRACT <br /> I Owner's Name si ,r Phone ,� � /� -3 <br /> Address' :fig ©' - <br /> City_ X00// <br /> Contiactorle ;Name License 5" Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7. RECONDITION /_ DESTRUCTION /_7 <br /> �o PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT17 <br /> Other J% <br /> DISTANCE TO NEAREST: SEPTIC TANK ;gip 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing, , » d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout 5e91 ' <br /> Cathodic Protection ^_7S Rotary Type of Grout /-T z <br /> —Disposal Other Other Information- <br /> Geophysical <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> F _Type of4Pump 4 c H:P. / <br /> PUMP REPLACEMENT: , <br /> . � / /,.;_Sate Work'Done"'=r�P�A�1 ...., , <br /> j PUMP':REPAIR: -.._.. .I� 'State-Work--Done - <br /> t� i � <br /> ES•TRUCTION OF WELL,-.-- Well Diaiu ter ..� .» Approximate� De <br /> �--.e � Depth'/ � � <br /> Describe-Material and Procedure <br /> I hereby}_agtee 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 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 INSPECTION <br /> PRIOR TO _GROUTIkjG ANDA EINAL INSPECTION. <br /> SIGNED , TITLE <br /> ,- (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL` COMMENTS: 1 <br /> S.iwPHASE II GOUT INSPECTION (,PHASE III FINAL INSPECTION <br /> INSPECTION BY %. DATE . /����� INSPECTION BY r DATE �Z <br /> j. �. ._ l . <br /> E H 1426 Rev. 1-74 1-74 2M . <br />