Laserfiche WebLink
,.s <br /> !YJ"/ SAN 30AQi3ri1 LOCAL HEALTH DISTRICT , <br /> FOR OFFICE USE; 01 E. Hazelton Ave. , Stockton, Calif. <br /> EIt�jj Telephone: (209) 466-6781 <br /> b LILA Z - LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -j1a_11] <br /> 76-2g3,v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3� <br /> (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 - — <br /> . ENSUS TRACT <br /> Owner's Name Phone <br /> Address City 7 <br /> Contractor's Name 112 A4 14A& License # '©,[Phone <br /> TYPE OF WORK (Check): NEW WELL -/7--`DEEPEN'/7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/7 PUMP REPLACEMENT f7 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .vQ,✓c SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD —c—t CESSPOOL/SEEPAGE PIT ,,---c OTHER XE• <br /> PROPERTY LINE PRIVATE DOMESTIC WELL -4o' PUBLIC DOMESTIC WELL d''c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ri <br /> �bl Domestic/private Drilled Dia. of Well Casing & i <br /> Domestic/public Driven Gauge of Casing a <br /> Irrigation Gravel Pack Depth of Grout Seal / <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> 12/a 4Geophysical ° Surface Seal Installed„'By <br /> PUMP INSTALLATION: C ntractor 0 F O WW�' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> RES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 FIFTEM 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 G UTING AND INS IQN <br /> SIGNED TITLE <br /> W OT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ^7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE - I,N�SPECTION BY ATE 57—/'2 <br /> 9M <br />