Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT V" <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 3 <br /> Telephone: (209) 466--6781 d <br /> APPLICATION F WEE-1 i�: flNSTRUCTI0 OR PUMP'PERMIT Permit No.7 l_3 F <br /> ---.THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 2- � ° <br /> 7j30 c7 ,E -C' -r oSp °r 1Jb'- (Compleke In Triplicate) ?�l--U�7 d� <br /> Applicaticsn is hereby 'made 'ti&-the San Joaquin Local health District for a permit o construct <br /> and/or instal. the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and' RegulatS <br /> o he San Joaquin Local Health District. ;! <br /> I CENSUS TRACT � <br /> 7- ifYn A...A ti ir A <br /> .TOE ADDRESSAOCATION S <br /> Owner's Name V 8 P, Phone <br /> . city <br /> Address .�. <br /> License <br /> one <br /> Contractor's Name\. a <br /> 6 Z,� <br />` TYPE OF WORK (Check): NEW WELL �/_7 DEEPEN /� RECONDITION � DESTRUCTION /_T <br /> PUMP CINSTALLATION / I Pte' REPAIR /✓I Pump REPLACEMENT f7 <br /> Other'h/ W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o <br /> SEWAGE­DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k <br /> Industrial - 1 Cable Tool Dia. of 'Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> t omestic/public :: Driven Gauge of Casing <br /> � a_ — Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Cathodic Protection ' Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical .- <br /> Surface Seal Installed B s <br /> _ . . <br /> PUMP INSTALLATION: Contractor •_R_- w '� �'''� 'f <br /> Type of Pump khe ID LU <br /> H.P. <br /> PUMP State/ !State Work Done <br /> PUMP '.REPAIR:_ F: /►�I `kState Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> z <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 con o work on a new 11;r ixwill furnish the San, iLocal Health District a <br /> WELL. LERS REPOR of th to 1 a yn tify them before putting ifie-yell. in.use.. The above <br /> infor tion tru o the be y owled e a I WILL',CALL F GROUT INSPECTION <br /> PRIOR TO GRO IN A► <br /> . ; TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �_ ,� <br /> . DATE ' <br /> APPLICATION-ACCEPTED BY <br /> ADDITIONAL''COMMEiTS PHA INSPECTION <br /> PHASE II._GROUT INSPECTION' INSPECTION BY DATE / <br /> INSPECTION BY DATE <br /> 21UI <br />