Laserfiche WebLink
� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton, Calif. <br /> FOE OFFICE CE USE: 160I E. HazelCon Ave. , <br /> �.� Telephone: (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> rr Date Issued �� <br /> THIS! PERMIT EXP�RES 1 .YEAR FROM DATE ISSUED <br /> (Coplete In Triplicate) permit to construct <br /> Application is hereby made�t&1the San Jo�quin LocallthisDistmade inrict Health <br /> compliance with San Joaquin <br /> and/or install the work herein describedeh This application <br /> No. l$62 and �the Rules and Regulations of �h�an Joaquin Local Health District.' <br /> County Ordinance1.Z / x,64 S, y�y,. ` <br /> ` mml CENSUS TRACT <br /> JOB ADDRESS/LOCATION l If <br /> 4 Phone �4 .'_.�.— <br /> Owner's Name I�%�A ® t ✓�� . . - i <br /> city <br /> Address <br /> h3� <br /> r Q License i�1C-13 73 PhoneL <br /> Contractor's Name ` '1 <br /> { I� RECONDITION / DESTRUCTION /_ <br /> I, TYPE OF WORK (Check) : NEW WELL I& DEEPEN / PUMP REPLACEMENT /_T ,y <br />` PUMP INSTALLATION SCI PUMP REPAIR <br /> Other <br /> r11 EWER LI ES . PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK -Q!I S _ OTHER <br /> CESSP_OOLISEEPAGE_PIT - _ rS <br /> SEWAGE;_DISP._OSAL-FIELD -- PUBLIC DOMESTIC WELL <br /> ,PROPERTY LINE - PRIVATE DOMESTIC WELL �— <br /> TypE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation /L' <br /> Industrial rr <br /> Drillted Dia. of Well Casing <br /> Domestic/private } Driven "Gauge of Casing <br /> Domestic/publicDe th of Grout Seal <br /> Irrigation Gravel Pack P <br /> Rotary Type of Grout <br /> Cathodic Protection Oth <br /> Disposal er Information ' <br /> Surface <br /> k <�� Surface Seal Installed B <br /> iv <br /> Geophysical <br /> 1 <br /> 4- f F <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of-P _ iM <br /> 4 PUMP REPLACEMENT: / / State;Workf Done <br /> st <br /> iState Work. Done <br /> � PUMP .REPAIR: � /4/i i <br /> " t E Approximate Depth _ <br /> I DESTRUCTION OF WELL: DescrDibemeter <br /> Mate ri`al and Procedure <br /> uin <br /> cal <br /> I hereby agree to comply <br /> with all laws and and regulations °wel�construction.LoWith naFIFTEENtDAYS* <br /> E and the State of California .pertaining to or regulating <br /> n Jo <br /> after completion of my work on a new well, I hemlbeforesputtingh the athewellaquinineuse.HeThe h above <br /> WELL DRILLERS REPORT of �the well and notify t <br /> y; __ _ . <br /> information true tory .1 est of m knowledge and belief .I� WIT�L`- CALL FOR A GROUT INSPECTION <br /> PRIOR-TO `GRO G D A ;— <br /> IF INSPECTIO TITLE <br /> SIGNED D W .p T PLAN ON RE gkSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I DATE (5 �O 72 <br /> PHASE i <br /> APPLICATION ACCEPTED BY I� <br /> .:._ <br /> ADDITIONAL COMMENTS: �! PHAS I FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> ' INSPECTION BY ��..��-- �� DATE �'-���i-7� <br /> 3/76 2M <br /> V u 1426 Rev. 1-74 <br /> f� <br />