Laserfiche WebLink
v' <br /> i 6 � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION ICOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�]Z_.3 a/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?-Z-_77 <br /> *� f (Complete In Triplicate) , <br /> Application is hereby made to the San Joaquin Local Realth,-District for a permit to construct <br /> and/or install the .work.herein described. This application is,made in compliance with San Joaquit <br /> County Ordinance No.,..1862 and the Rules and gulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION:_-,?,Arrte_OT Leh h'L z ke-6 ils, J5. CENSUS TRACT <br /> Owner's Name a h , Phone <br /> f Address 3 {� i Ll Pd City <br /> Contractor's Name License # , gD�C3 Phone 2- f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /- DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 1 f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK //Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C` <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> F 'INTENDED USE,-' TYPE OF WELL CONSTRUCTION SPECIFICATIONS St <br /> Industrial,` Cable Tool Dia. of Well Excavation ' tf <br /> Z Domestic/private Drilled . Dia. of Well Casing <br /> G .,Domestic/public", Driven Gauge of Casing 1,h (��} <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection ► _� Rotary, Type of Grout <br /> Disposal Other Other .Information <br /> Geophysical # Surface Seal Installed BI : he <br /> " PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / � State Work Done <br /> - � � <br /> -s-tate. Work_Done -� <br /> ,PES;TRUCTION OF WELL: Well Diameter ., Approximate Depth <br /> ® Describe Material and Procedure <br /> \ � "F <br /> I hereby agree to comply with all laws and regulations of the San Joaquip,Local Health District <br /> 1k{ 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-.Realth 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 PROUTING D FINAL I SPECT QN, j <br /> SIGNED TITLE <br /> Pkff LA <br /> ON REV RSE SIDE <br /> FOR DE T NT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEP —� A DATE <br /> ADDITIONAL CO Si <br /> a E OUT INSPECTIN PIASK IINgIM INSPECT - N <br /> INSPECTI BY l DATE INSPEC BY ATE -, �` <br /> f <br /> `' E H 1426 Rev. 1-74 1-74 2M <br />