Laserfiche WebLink
/a4,�O SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FPF OFF CE USE: 1601 E. Hazelton Ave . , .Stockton, Calif. <br /> Telephone: (209) 466-6781 UUU <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, -7-7-119-2) <br /> THIS .P.ERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local.., Health District for a permit to construct <br /> and/or znsall. the work herein described. This application. is .made, in compliance with San Joaquin <br /> County Ordinance No. 1$62. and the Rules and .Regulations of .the San. Joaquin Local' Health .District. <br />' JOB ADDRESS/LOCATION w° v: pENsvS TRACT pg —b <br /> - `f-0 <br /> Owner's Name n+► ! Phone <br /> Address r 't° ` <br /> 0�1 f City AZ <br /> A,191 <br /> Contractor's Name <br /> License # hone <br /> Iff <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / `RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION 4Xe/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other,'.!/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private.,, "I Drilled - Dia. of Well Casing <br /> �X Domestic/public Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protdction F 'Rotary Type of Grout <br /> Disposal :, A. Other Other Information j <br /> Geophysical p Surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump <br />`PUMP REPLACEMENT: / / State Work Done <br /> PUMP . ,.: <br /> State Work Done <br /> ! f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating wrell '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 DRILLERS REPORT of the well and notify them before putting thewell in use.. The `above <br /> information is true to the best of- my wled 'e and lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UT G AND A FINAL IINSP l <br /> SIGNED / TLE Ron <br /> (D W O ON RE SE SIDE) <br /> PHASE I <br /> R`DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY` }� DATE INSPEGTION BY DATE <br /> E H 1426 Rev. • 1-74 f x/77 _ 2Mv-' <br />