Laserfiche WebLink
f - '--, J_-- rV — n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEyOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif, �� f- <br /> Telephoner (209) 466-6781 *Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7&6.UIV <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby madlo 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 010 5� G IAI co G A/ /? p CENSUS TRACT <br /> t _ <br /> ! <br /> Owner's Name 1ao 4-` Phone -Zjr 411 <br /> Address 0 s IN GOL Al 19 City g 7-1KA, - .._. <br /> Contractor's Name M b S � �- �!L L IA16 License 4� 4 DZ Phone '7/!5"��� r <br /> TYPE OF WORK (Check) : NEW:WELL / DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /-7 <br /> I PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /-7 <br /> 4 Other <br /> I <br /> I DISTANCE TO NEAREST: SEPTIC-TANK—L,(t6 --SEWER-LINES— PDT-PR1-'V-Y <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 /> IndustrialT-Cable Tool Dia'. of Well Excavation / '2, <br /> Domestic/private Drilled a Dia, of Well Casing <br /> Domestic/public Driven Gauge-of <br /> Irrigation Gravel Pack. Depth of Grout Sea-1-- <br /> Cathodic <br /> eal-Cathodic Protection Rotary Type of Grout <br /> Disposal Other `°-Othe-k Information j <br /> Geophysical Surface Seal Installed By:_ _ C <br /> PUMP INSTALLATION; Contractors`1 G "' <br /> Type of rump - H.P. <br /> PUMP REPLACEMENT: .- / / State Work Done` <br /> PUMP .REPAIR: / / State Work Done S <br /> DESTRUCTION OF WELL: We11,.Diameter----- Approximate Depth t <br /> Describe Material and Procedure <br /> � f . <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 DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERt- 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 GROdTING AND A FINAL INSPECTION. I r <br /> SIGNED _ LE <br /> Yr.:. L T'F ON RSE SIA , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I,. „�-: <br /> APPLICATION_AC..Q TED BY DATE' T <br /> ADDITIONAL COMMENTS: it7 <br /> P S IOUT INSPE IO P . IIF NAL INSPECTIO <br /> INSPECTION BY DATE a• INSPECTION BY DATE 9 1-2-, <br /> } - -74 3/76 <br /> E H 1426 Rev. <br />